Agent Code (DON'T FORGET!)
Patient - Last Name
Address - City
Patient - Last Name
Patient - Middle Name
Address - Street/House Number
Address - State
Address - Zip Code
Primary Phone
Mobile Phone / Alternate Number
Email Address
Gender/Sex
Date of Birth
Height (in inches)
Weight (in pounds)
PRIVATE INSURANCE COMPANY
PRIVATE INSURANCE Member ID
PRIVATE INSURANCE PHONE NUMBER
PRIVATE INSURANCE RX GRP
PRIVATE INSURANCE PCN
PRIVATE INSURANCE BIN
MEDICARE INSURANCE NAME
MEDICARE INSURANCE ID
WHAT TYPE OF PAIN? Sporadic, Frequent or Chronic
PAIN LOCATION? - back, neck, shoulder, elbow, leg , knee or head
Probable conditions that aggaravated pain?
PAIN LEVEL ON A SCALE OF 1 - 10
FREQUENCEY OF PAIN - sporadic/frequent/chronic
HOW LONG WAS THE PATIENT IN PAIN?
WHAT ORIGINALLY CAUSED THE PAIN? Injury/Surgery/illness/arthritis etc..
Additional Info on Pain/Injury
Treatemet used or taken to aid in pain relief
Has the patient received a back brace in the last 5 years?
If patient had received a back brace - What type?
Is the patient in the process of receiving a back brace from other provider?
PRODUCTS PATIENT HAS INTEREST? brace, what type / medications, what type
Pant Size Waist (Collect for Knee/Back)
Pant Size Leg (Collect for Knee)
Shoe Size (Collect for Ankle/Foot/Knee)
- Current Medical Conditions
Previous Surgeries? If yes, Explain type of Surgeries
Is patient a Diabetic?
Average Cholesterol Level
Any Allergies to medications?
Any Over the Counter Medications patient is taking?
Prescribed Medications Patient is taking
Any Skin problems or Allergies?
Skin Creams or Lotions Allergies?
Related surgery or injury dates
Pregnant or plan on becoming pregnant?
Patient Wants Pain Cream?
RX SECTION - Patient Wants Scar Cream? Where is scar located?
RX SECTION - Patient Wants Acid Reflux ?
RX SECTION- Patient Wants Psoriasis/Eczema ?
RX SECTION - Patient Wants Metabolic Tablets?
Any family members with any type of cancer? What type?
LAB SECTION - what is the patient relation to one with cancer?
LAB SECTION - DOES THE PATIENT WANTS A CANCER SCREENING TEST?
LAB SECTION- does the Patient Wants PGX Test?
FULL NAME
PRIMARY CARE PHYSICIAN PHONE NUMBER
PRIMARY CARE PHYSICIAN EMAIL
Did patient visited Primary Care Physician from Last Year?
Had the patient had a Wellness visit in the last year?
Seen PCP for Injury or Pain (If yes then mention reason)
Reasons PT believes the braces will benefit to him/her?
FOR DOCTOR - Goals why patient will use braces
Contact Method for Doctor to contact patient
BEST TIME TO CONTACT PATIENT FOR A CALLBACK? AM/PM/early Evening
Additional Notes for the Doctor
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