New Patient Form — Precision Osteopractic

Email

Age

Gender assigned at birth:

Body Region

Tell us the primary reason for this visit:

When did symptoms start:

With time symptoms are:

On a scale of 0 to 10, what is the intensity of your pain?

0 = No Pain | 10 = Worst Pain Imaginable

What makes your symptoms better?

What makes your symptoms worse?

Have you had previous treatment for this problem?

If yes, please briefly describe below:

Any previous Diagnostic Imaging (X-ray / MRI) for this problem?

Occupation:

On a scale of 0 to 10, how would you rate your level of function?

0 = Cannot do anything | 10 = Able to do everything

General Health?

If Yes, please explain below:

Please list current medications: (Prescription and OTC)

What is your main goal you want to accomplish working with Precision OPT?

Are there any other injuries or conditions we need to be aware of?

Do you have a history of any of the following? (Select Yes or No)

Are you currently experiencing any of the following?

Please type your Full Name to serve as your electronic signature:

Consent: My diagnosis and treatment plan will be discussed during my appointment and I understand that I have the right to question and/or refuse any treatment offered. I attest that the information I have provided above is accurate and complete to the best of my knowledge.

New Patient Information

emerson wellevate

Precision Physical Therapy, LLC

two convenient locations

33 Morgan Drive, Lebanon NH 03766

53 south main st, ste. 211, hanover nh 03755