Non Accident Intake Form For Salumed This form is used for our physicals only. Our website is secured by McAfee SSL certificate. Your privacy is our #1 concern. Step 1 of 7 14% What type of visit is this for? (select all that apply)* Medical Chiropractic Massage Therapy DOT Physicals Name* Mr.Mrs.MissMs.Dr. Prefix First Middle Last Email* Enter Email Confirm Email Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Sex* Male Female Date Of Birth* MM slash DD slash YYYY AgePlease enter a number from 0 to 100.Marital StatusSingleMarriedOtherHome Phone*Cell Phone Occupation Employer Employer Phone Do you have a family doctor? Yes No Name of Family Doctor Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Last Visit MM slash DD slash YYYY Date of Last Exam MM slash DD slash YYYY Have you had surgery in the last 5 years? Yes No Date of last surgery MM slash DD slash YYYY Reason for Surgery Present Illness or Conditions*AIDSAllergiesAnemiaArthritisAsthmaBone FractureCancerCirrhosis/HepatitisDiabetesDislocated JointsDiverticulitisEpilepsyEmotional DifficultyFrequent UrinationHay FeverHeart ProblemHigh Blood PressureHIV/ARCKidney/Bladder/UrinaryLeakage if Sneeze/LaughLoss of Bladder ControlLow Blood PressureMultiple SclerosisNighttime UrinationPacemakerProstate TroublePolioRheumatic FeverScoliosisSinus TroubleSpinal Disc DiseaseSTD'sThyroid TroubleTuberculosisUlcerNone of the aboveUse the CTRL key to select multiple itemsType of Cancer Breast Lung Other Other Type of Cancer Family History of Illness*AIDSAllergiesAnemiaArthritisAsthmaCancerBone FractureCirrhosis/HepatitisDiabetesDislocated JointsDiverticulitisEpilepsyHeart ProblemHIV/ARCHigh Blood PressureKidney TroubleLow Blood PressureMental/Emotional DifficultyMultiple SclerosisProstate TroublePolioRheumatic FeverScoliosisSpinal Disc DiseaseSTD'sSinus TroubleThyroid TroubleTuberculosisUlcerNone of the aboveUse the CRTL key to select multiple itemsType of Cancer (Family) Breast Lung Other Other Type of Cancer (Family) Do you drink alcohol? Yes No Drinks per week?Is alcohol use a concern for you or others? Yes No Do you smoke cigarettes? Yes No Packs per dayDo you use any recreational drugs? Yes No Have you ever used needles to inject drugs? Yes No Do you drink caffeine? Yes No Drinks per dayDo you exercise? Yes No How may hours per week?How often? What type of excercise is it? Light Moderate Strenuous What kind of excercise? Why do you not exercise? Reason for Visit* Let us know why you are coming into the office.Constitutional* Recent fevers/sweats Unexplained weight loss/gain Unexplained fatigue/weakness None Respiratory* Cough/wheeze Coughing up blood None Are you on any prescription or non-prescription medicine?* Yes No This includes vitamins, home remedies, birth control pills.List of medication*MedicationDose (e.g., mg/pill)How many times per day Do you have any allergies or reactions to medicines?* Yes No Allergies or reactions to medications* How do you rate your diet? Good Fair Poor Are you taking any vitamins? Yes No What brands do you take? 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