New Patient Intake (Review Draft)

Review draft for Cameron — nothing here is sent or saved. Fill it in like a patient would, tap Submit at the bottom, and you'll see exactly what Cameron would receive. The live version's questions, safety routing, and where submissions go are all Cameron's call.

First — new or returning?

Returning patients skip the full form and just report what changed.

About you

Full name Phone Email Preferred contact method How did you hear about us?

What brings you in?

Main concern / body area What do you want to get back to doing? How and when did it start? Since it started, it has been…

Pain & symptoms

Pain right now (0–10)

Worst pain in the last week (0–10)

Any of these going on? (check all that apply)

What makes it better or worse?

Safety check

These help Cameron decide whether you need a call before your visit. Check any that apply — this form is not a diagnosis tool.

Draft routing (Cameron to approve): in the live version, checking any of these would prompt a call from the clinic before the visit rather than simply waiting for the appointment — and urgent symptoms would be directed to urgent care or 911 guidance.

Background

Relevant prior care (check all that apply)

Anything Cameron should know about that care? Records or a referral to bring to the visit? Medical conditions or medications that could affect therapy Allergies or sensitivities relevant to treatment

Planning your visit

Where will your visit be? Anything that helps Cameron plan — home access, parking, pets, stairs, equipment Anything else?

Mobile Motion — New Patient Intake