Confidential Patient Information — DeFabio Spine & Sports Rehab

1

Patient Information

Today's Date

Patient Name

Date of Birth

Social Security #

– –

Street Address

City

State

Zip

Home Phone

Work Phone

Cell Phone

E-mail

Preferred Language

Race

Smoking Status

Never Former Current

Referred By

Primary MD

Employer / School

Occupation

Employer / School Address

Emergency Contact

Emergency Contact Phone

2

List present complaints and injuries

How long have you had this condition?

Frequency

Occasionally Frequently Constantly

Who else have you seen for this condition?

What did they recommend?

3

Pain Location — tap the figure where you experience pain (tap a dot to remove)

FRONT

BACK

4

By signing below, I consent to be evaluated and treated by DeFabio Spine and Sports Rehab, LLC.

Patient Signature for Consent to evaluate and treat today

Sign here

Date