New Patient Information

New Patient Information

Please bring the following items with you to your appointment: • Valid Photo ID • Insurance Cards • Previous medical records and MRI reports associated with your pain condition. On your initial consultation we will perform an evaluation and assess your medical condition. Boxes marked with a red * are required. YOU WILL SEE A "SUBMITTED" MESSAGE AFTER YOUR PRESS THE "SUBMIT" BUTTON AT THE END OF THE FORM. Thank you for choosing The Brooks Accident & Injury Clinic.

Male Female
Office LIght Labor Heavy Labor
Yes No

If yes, please give dates.

Yes No

I acknowledge that The Brooks Accident & Injury Clinic can send me text messages or email of my appointment reminders

Emergency Contact

General Information About Your Injury

Yes No
Yes No
Yes No
Yes No
Driver Passenger
Yes No

Please include City

Ambulance Private Car
Xray MRI Pain Medication

Tell Us About Your Accident Pain & General Health

Neck Low Back Headache Chest Stomach Right Shoulder Left Shoulder Right Arm/Wrist Left Arm/Wrist Right Hand/Fingers Left Hand/Fingers Right Knee Left Knee Right Leg/Hip Left Leg/Hip Right Ankle/Foot Left Ankle/Foot Other

Mark All That Apply

Yes No
Yes No
Latex Tape Iodine Other
Yes No

If answer is YES please bring your list to your exam. If answer is NO, please enter your medications in the space below.

Aspirin Anti-Inflammatory Lovenox Coumidan Warfarin Pletal Aggrenox Pradaxa Ticlid Plavix Heparin
Never Occassionally Frequently
Gallbladder Appendix Hernia
CABG Valve Repair Aneurysm Stent Placement Vascular
Fusion Laminectomy Discetomy
Hip Knee Elbow Shoulder
Hysterectomy Tubal Ligation C-Section Other
Yes No

Family Medical History

Please check any medical conditions and indicate the family member associated: Self / Mother / Father

Self Mother Father
Self Mother Father
Self Mother Father
Self Mother Father
Self Mother Father
Self Mother Father
Self Mother Father
Self Mother Father
Self Mother Father
Self Mother Father
Self Mother Father
Self Mother Father
Self Mother Father
Self Mother Father
Self Mother Father
Self Mother Father
Self Mother Father
Self Mother Father
Self Mother Father
No significant family medical history I am adopted

Patient Medical History (Before The Accident)

Chills Fatigue Fever Night Sweats Other
Numbness / Tingling Seizures Memory Impairment Weakness Incontinence Loss of Balance Loss of Coordination Other
Neck Pain Low Back Pain Muscle Weakness Morning Stiffness Joint Pain Joint Stiffness Difficulty Walking Other
Blurred Vision Photophobia (Light Sensitive) Visual Changes Other
Depression Anxiety Suicidal Thoughts Sleep Difficulty Restlessness Crying Agitation Insomia Ohter
Rash Hives Other
Hearing Changes Bleeding Gums Dental Problems Other
Cough Wheezing Shortness of Breath Other
Hair Loss Excessive Thirst Other
Chest Pain Palpitations Fast Heart Rate Slow Heart Rate Edema (swelling) Other
Taking Blood Thinners Easy Bruising Excessive Bleeding Swollen Glands Other
Diarrhea Constipation Nausea / Vomiting Abdominal Pain Jaundice Reflux Other

Electronic Signature

Yes No

I acknowledge that this electronic signature represents my true signature and will be used throughout this patient information form. Anywhere I type my name, I intend this to be my legally binding signature.

Referral To The Brooks Clinic

TV: KFOR 4 TV: KOCO 5 TV: KWTV 9 TV: Fox 25 TV: The CW TV: KAUT 43 TV: Cable or Satellite Other Internet Search Facebook Friend / Relative Billboard I am a Former Patient Phonebook Sign on Building (drive by) Radio: KVSP (Perry) Radio: KYSS Other Doctor / Hospital / ER Attorney

If referred by a doctor or medical facility, please give name

If referred by an Attorney, please give name