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PPG Intake Form
A problem was detected in the following Form. Submitting it could result in errors. Please contact the site administrator.
First Name
Last Name
Contact Email
Date of Birth
Age
Sex
Select...
Female
Male
Prefer not to say
Height
Weight
Are you:
Select...
Right handed
Left handed
Both
Employer at the Time of Injury
Are You Working Now?
Select...
Yes
No
Occupation at the Time of Injury
Date of Injury
Location of Injury
Briefly describe what happened:
If you're having continued difficulty as a result of the injury, what problems are you having and what makes the condition worse?
List medications you are currently taking, including over the counter (if any)
List allergies or reactions to medications (if any)
Year
Surgery Type
Add Another Surgery?
No
Yes
Year
Surgery Type
Add Another Surgery?
No
Yes
Year
Surgery Type
More than 3 Surgeries?
No
Yes
Additional Surgery Information:
Type of Study
When
Where
Add Another Study?
No
Yes
Type of Study
When
Where
Add Another Study?
No
Yes
Type of Study
When
Where
More than 3 Studies?
No
Yes
Additional Study Information
Have you been previously treated for this condition?
No
Yes
When and Where?
Do you smoke or use tobacco?
No
Yes
If yes, what and how much?
Do you use alcohol?
No
Yes
If yes, what and how much?
Check appropriate history of medical conditions
Heart Condition
Phlebitis / Blood Clots
Thyroid
Mental or Emotional
Cancer
High Blood Pressure
Asthma / Emphysema / Lung
Hepatitis / Liver
Lyme's Disease
Epilepsy / Seizure
Circulation
Diabetes
Kidney or Bladder
Stroke
Authorization & Understanding
I hereby authorize Prime Physicians Group to exaine me for the purpose of performing an Independent Medical Evaluation. I also understand that the examination to be performed has been requested by a third-party, and that a written report will be sent to that individual who requested the exam. Furthermore, I am aware that this examination is to address specific injuries, conditions, or questions outlined by the requesting party. I understand that it is not meant to constitute a general medical examination nor substitute the services of a personal physician or health care provider. Medical advice or treatment will not be provided and no physician-patient relationship Finally, during the examination, I am aware that I should not engage in any physical maneuvers beyond what I can tolerate or which I feel is beyond my limits or which I feel could cause physical harm of injury.
You must accept this agreement to submit this form.
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