Wellness Center Intake Form

First name

Last name

Date of Birth

Phone

How will you attend?

Address

___________________________________________________________________

Emergency Contact

First Name

Last Name

Relationship

Phone

___________________________________________________________________

Insurance Provider

Insurance Plan

Policy Number

Contact Number

Group Number

Social Security Number

___________________________________________________________________

Are you currently under medical care?

Yes

What are you currently under medical care for?

Primary Care Physician

___________________________________________________________________

How many times have you been to the hospital since your last visit?

How many times have you gone to the Emergency Department since your last visit?

How many times have you gone to the Urgent Care since your last visit?

___________________________________________________________________

What is your currently pain level?