New patient intake Any fields marked with a red asterisk are required. All other information is optional. AOA IntakeBasic informationPlease fill out the following.First NameLast NameDate of BirthAddressAddress Line 1Address Line 2CityStateZip CodePhone/MobileChief complaint (reason for visit):Medical history Arthritis Cancer Diabetes Heart disease Hypertension Stoke Thyroid conditionAre you experiencing any of the following symptoms? Dizziness Double vision Headache Chest pain Swelling of the anklesAdditional informationPlease answer the remaining required fields:Do you take any medications? Yes NoPlease list any medications:Have you had any surgeries? Yes NoPlease list any surgeries:Do you consume caffeine? Yes NoIf yes, please describe the frequency/volume:Do you consume alcohol? Yes NoIf yes, please describe the frequency/volume:Do you smoke cigarettes? Yes NoIf yes, please describe the frequency:Do you exercise? Yes NoIf yes, please describe the frequency and type of exercise:If you are experiencing any other symptoms/concerns, please describe them below:Signature (please type your name as you would sign it): I consent to and confirm my digital signature above to be used in place of my written signature. I have read Art of Anatomy's consent information and knowingly/willingly consent to treatment. I have read and understand my rights under HIPAASubmit Form
