Sports Medicine Intake Form
Personal Information
Full Name
Date of Birth
Phone Number
Email Address
Address
Emergency Contact
Contact Name
Contact Phone
Relationship
Insurance Information
Provider Name
Policy Number
Current Injury/Concern
Describe your current injury or concern
Date of Injury/Onset
Side of Body
Left
Right
Both
N/A
What aggravates your symptoms?
What eases your symptoms?
Activity & Medical History
Sports/Activities You Participate In
List any ongoing medical conditions
Past injuries or surgeries (with dates, if possible)
Allergies (including medications)
Current Medications