Patient Forms Our Services New Patient Form If you’re a new patient to neurokinetixga, please complete and submit before your first appointment. GenderYesNo Date of Birth Address Contact Preferred Contact Method HomeMobileEmail Emergency Contact Referred By WebsiteWord of mouthMDOther Medical History Today’s Date General Information Is this injury related to WorkCar AccidentOther Liability/ LawsuitOther Do you have a Primary Care Physician/ Family Doctor? YesNo If yes, have you had an appointment with him/ her in the last 12 months? YesNo Race/ Ethnicity Caucasian (White)African AmericanHispanic or Latino OriginEskimo/InuitAsianNative AmericanOtherDeclined Please Mark One Box for Each Item Alzheimer’s YesNo Cardiovascular Disease YesNo Cauda Equina Syndrome YesNo Cerebral Vascular Accident YesNo Current Infection YesNo Diabetes Mellitus Type 1 YesNo Diabetes Mellitus Type 2 YesNo Fibromyalgia YesNo Fracture or Suspected Fracture YesNo High Blood Pressure YesNo History of Cancer YesNo Huntington’s YesNo Immunosuppression YesNo Lupus YesNo Muscular Dystrophy YesNo Obesity YesNo Osteoarthritis YesNo Parkinson’s YesNo Rheumatoid Arthritis YesNo Traumatic Brain Injury YesNo Other YesNo Please write your pertinent Surgical History Have you had treatment for this injury in the past? If so, when? Do you have latex allergies or any other allergies? Please Mark One Box for Each Item Heart Condition YesNo Chest Pain YesNo Stroke YesNo Kidney Condition YesNo Blood clot/ DVT YesNo Pacemaker YesNo Sexual Dysfunction YesNo Bladder/ bowel problems YesNo Groin numbness YesNo Osteoporosis YesNo Head Injury YesNo Headaches YesNo Depression YesNo Breathing difficulty/asthma YesNo Unexplained Weight Loss YesNo Double Vision YesNo Night Sweats/ Night Pain YesNo Metal implants YesNo Psychological condition YesNo Seizures YesNo Dizziness/fainting YesNo Ringing in Ears YesNo Allergy to latex (gloves) YesNo Fever/ nausea YesNo Are you pregnant? YesNo Other Allergy YesNo
