New Patient Intake Form - First Choice Medical Center

Apply For Neuropathy Treatment

Step 1 of 5

First Choice Medical Center

1157 - 3rd Avenue, Suite 145, Longview, WA 98632

Application for Neuropathy Treatment

Full Name *

Email *

Phone *

Address *

City *

State *

Postal code *

SSN # / SIN # *

Date of Birth *

Occupation

Name of Spouse

Review of Systems

*

Present Health Condition

In order of importance, list the health problems you are most interested in getting corrected. *

List approximately how long you have noticed these problems. *

Is there a certain time of day any of these problems are better or worse? *

Is your balance/walking ability affected? If yes, please describe. *

Which of these have you used for these problems? *

What do you think is causing the problems? *

Name of all doctors seen for these problems and treatment received. *

Have Your Symptoms: *

Improved

Worsened

Stayed the Same

Is there anything that makes your condition worse? *

How would you describe the symptoms? *

Social History

Are you:

Smoker

Drinker

Exercise Regularly

Current Pain Levels

Please select all conditions that apply to you.

Endocrine

Thyroid

Diabetes Type 1

Diabetes Type 2

Abnormal Organs

Hepatitis

Liver Cirrhosis

Gallbladder

List all medications currently taking. *

Who may we thank for referring you?