NEW PATIENT INTAKE
Intake Form
Name
Last Name / Sobrenome / Apellido
Address
Address Line 1
Address Line 2
City
State
Zip Code
Country
Select Country
Brazil
United States (US)
Afghanistan
Aland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belau
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
British Indian Ocean Territory
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo (Kinshasa)
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Ivory Coast
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao S.A.R., China
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palestinian Territory
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo (Brazzaville)
Reunion
Romania
Russia
Rwanda
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin (Dutch part)
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia/Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom (UK)
United States (US) Minor Outlying Islands
United States (US) Virgin Islands
Uruguay
Uzbekistan
Vanuatu
Vatican
Venezuela
Vietnam
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
DOB / Date de Nasc. / Fecha de Nacimiento
Email
Telephone
Gender / Sexo
– Select –
Male
Female
Age / Idade
Are you pregnant? / Estas Gravida? / Estas embaracada?
When in doubt say YES
Yes
No
How many weeks pregnant? / Quantas semanas?
What brings you in? / Qual a razão da sua visita? / ¿Qué te trae?
How long ago has this been bothering you? / Desde quanto te incomoda? / ¿Cuánto tiempo hace que esto te ha estado molestando?
What makes it worse? / O que faz o sintoma piorar? / ¿Qué lo empeora?
What makes it better? / O que faz melhorar? / ¿Qué lo hace mejor?
Other important details about it? / Outros detalhes importantes sobre esse problema? / ¿Otros detalles importantes al respecto?
Have you been to a Chiropractor? / Já se tratou com um doutor em Quiropraxia? / ¿Has estado en un quiropráctico?
– Select –
Yes
No
Where were you treated?/ Em que país? / ¿Dónde te trataron?
Different countries has different standards of care for Chiropractic medicine.
Afghanistan
Aland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belau
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo (Kinshasa)
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Ivory Coast
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao S.A.R., China
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palestinian Territory
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo (Brazzaville)
Reunion
Romania
Russia
Rwanda
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin (Dutch part)
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia/Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom (UK)
United States (US)
United States (US) Minor Outlying Islands
United States (US) Virgin Islands
Uruguay
Uzbekistan
Vanuatu
Vatican
Venezuela
Vietnam
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Have you treated this condition with another physician? / Tratou desse problema com outro profissional? / ¿Ha tratado esta condición con otro médico?
– Select –
Yes
No
Which treatments have you done so far? / Qual tratamento você procurou? / ¿Qué tratamientos ha realizado hasta ahora?
Chiropractic
Neurologist
Orthopedic
Medication
Pain Management Dr
Massage
Physical Therapy
Other
have you suffered any car accident in the past ? / Sofreu algum acidente de carro no passado? / ¿Has sufrido algún accidente de coche en el pasado?
– Select –
Yes
No
How long ago was the accident? / Quanto tempo atrás foi o acidente? / ¿Hace cuánto fue el accidente?
Any surgery in the past? / Algum histórico de cirurgia? / ¿Alguna cirugía en el pasado?
– Select –
Yes
No
List the surgeries and year it was performed / Descreva que cirurgia e ano da operação / Enumere las cirugías y el año en que se realizó
Do you have a history of AVC? / Você tem histórico de AVC? / ¿Tiene antecedentes de AVC?
– Select –
Yes
No
Do you drink Alcoholic Beverages? / Você consome bebidas alcoólicas? / ¿Tomas Bebidas Alcohólicas?
– Select –
Yes
No
Do you smoke cigarettes? / Fuma cigarro? / ¿Fumas cigarrillos?
– Select –
Yes
No
Do you use medical marijuana? / ¿Usas marihuana medicinal? / Faz uso de maconha medicinal?
– Select –
Yes
No
Current medications / Medicações que toma / Medicamentos actuales
Can we send txt reminders for you appointments? / Podemos enviar confirmação via txt? / ¿Podemos enviar recordatorios de txt para sus citas?
– Select –
Yes
No
How can we confirm your appointments? / Como podemos confirmar sua consulta? / ¿Cómo podemos confirmar sus citas?
How did you know about Prospine? / Como ficou sabendo da Prospine? / ¿Cómo supiste de Prospine?
– Select –
Friend/Family/Colleague
Google
Billboard / Outdoor
WhatsApp group
Facebook
Website
Instagram
Walk-in
Name of friend/family/colleague / Nome do amigo/colega / Nombre del amigo/familiar/colega
I agree to send my information electronically to ProSpine Orlando to be reviewed by its doctors for consultation purposes. I understand that my information will not be shared with third parties and will be used solely by Prospine doctors for future examination, evaluation and/or treatment.
Acepto enviar mi información electrónicamente a ProSpine Orlando para que sus médicos la revisen con fines de consulta. Entiendo que mi información no se compartirá con terceros y será utilizada únicamente por los médicos de Prospine para futuros exámenes, evaluaciones y/o tratamientos.
Eu concordo em enviar minhas informações eletronicamente para a ProSpine Orlando para serem revisadas por seus médicos para fins de consulta. Entendo que minhas informações não serão compartilhadas com terceiros e serão usadas exclusivamente pelos médicos da Prospine para futuros exames, avaliações e/ou tratamentos.
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