Urgent symptoms If you currently have sudden paralysis, new loss of bladder or bowel control, severe chest pain, severe breathing difficulty, or symptoms of stroke, seek emergency medical care rather than waiting for a clinic appointment.

Patient Intake and Consent Form

Please complete this form before your first appointment. Your answers help the clinical team prepare for your consultation.

Patient Information

Full legal name in English Date of birth Sex Civil ID / Passport Number Nationality Phone Number Email Preferred language Occupation Marital status

Address

Emergency Contact

Name Relationship Phone Number

Appointment Reason and Clinical History

Main Reason for Appointment

When did the current problem begin? How did it begin? Have you had this problem before? Was this related to an accident, work injury, or sports injury?

Primary complaint details

Pain or symptom location What side is the pain on?

Pain now Worst, past 2 weeks Best, past 2 weeks Average, past 2 weeks

How would you describe the symptoms?

What makes it worse? What makes it better? Does the pain travel or radiate? Where? How does this affect work, sleep, exercise, prayer, driving, or daily activities? What would you most like to achieve from care?

Do you have another complaint you would like assessed?

Medical History

Current medical diagnoses Previous surgeries and dates Current prescription medications, dose, and reason Over-the-counter medicines and supplements Medication, food, latex, or other allergies and reactions Implants, pacemaker, spinal hardware, or metal in the body

Have you ever been diagnosed with any of the following?

Primary care doctor / specialist names Previous imaging or tests, dates, and facilities Previous treatment and response Relevant family medical history

Safety Screening

Please answer carefully. A “Yes” answer does not necessarily mean treatment is unsuitable, but the clinician may need more information.

Pregnancy and Imaging Safety

Are you currently pregnant or could you be pregnant? Are you breastfeeding?

Lifestyle

Exercise type and frequency Smoking / vaping (how many a day) Alcohol use (how much per day / week / month) Typical sleep duration and quality

Insurance and Documents

Insurance company Policy / membership number

Documents and Attachments

Insurance Information Identification Document Previous Medical Records Referral Letter

Additional Clinical Notes

Consent and Signature

Patient / guardian signature

Signer full name Date