New Patient Form

1.Patient name:

2. Gender

Male Female

3. Date of birth:

4. Telephone:

5. Email address:

6. How did you hear about us?

Family/friend/co-worker On-line search Osteokinez website
Facebook Other

7. What is the main reason for your visit?

8. How long has the pain (or your problem) been present?

9. What in your opinion started the pain or problem?

10. Do you have any pins and needles, tingling, numbness in your upper or lower extremities? If yes, where exactly?

11. Have you previously had any serious traumas, car accidents, falls, and/or fractures?

YearWhat happened?

12. Have you had any surgeries?

YearWhat surgery did you have?

13.Please list any major illnesses you have had/are still having (cardio-vascular, gastrointestinal, genitourinary, respiratory, hormonal, psychiatric, neurological etc)

IllnessWhen was it diagnosed?

14. Are you currently taking any medications?

Name of medication Dose Duration

15. Have you had any clinical diagnostic tests over last 5 years? (X-Ray, MRI, ultrasound, blood work, CT scan, bone scan etc)

YearType of the testWhat was found?

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16. Is there any medical information of importance not indicated on this form?