Patient Check-In Form - University Health Center

Patient Intake Form . . .	Please fill out the form completely

How did you hear about us? (please check one)

Mall Promotion

Wal-Mart Promotion

Yellow Pages

Internet

Current Patient or Friend please specify:

Doctor Referral please specify:

Attorney Referral please specify:

Other (not listed above) please specify:

Personal information:

First / Last Name:

Date of Birth: ,

SSN #: - -

Cell Phone: ( ) -

Home Phone: ( ) -

Work Phone: ( ) - Ext.

Street Address:

Apt. / Suite #: Number:

City: State: Zip Code:

Email:

Occupation:

Emergency Contact:

Emergency Phone: ( ) -

Questionnaire:

Do you have any pain or discomfort?

Yes No (please check one)

If Yes, What areas?

Any health conditions
we should be aware of?

Have you had Massage therapy before? Yes No (please check one)

Have you had Chiropractic therapy before? Yes No (please check one)

Have you had Physical therapy before? Yes No (please check one)

Have you been in an automobile accident? Yes No (please check one)

If Yes, When?
,

If Yes, Where?

Do you have Health Insurance? Yes No (please check one)

If Yes, What is the Company name?

What type is it? PPO/POS HMO Medicare/Medicaid

Do you have a Secondary policy? Yes No (please check one)

If Yes, What is the Company name?

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you must enter the security code into the box provided: