NEW PATIENT INTAKE FORM

NEW PATIENT INTAKE FORM

Aligned with Dr. Kim provides our patient form online so you may complete it in the convenience of your own home or office. When

completed, you may fax us your printed and completed form or bring it with you to your appointment.

Personal Information

Please choose
Please choose

WHAT BROUGHT YOU INTO THIS OFFICE:
If you have no symptoms or complaints and are here for Optimal Health & Wellness Services, please skip to the “General Health History”.

Health Concerns - Please list your health concerns according to their severity

Rate of severity
Rate of severity
Rate of severity

Provocation/Palliation

Quality

Region/Radiation

Other doctors you have seen for this condition:

Doctor's details

Have you been "forced" or "felt the need" to make any "positive" changes in your life due to this pain, illness, condition, etc? (i.e., eat better, less alcohol or drugs, meditate or breathe more, less destructive sports, activities, etc.)

Is this condition interfering with any of the following:

Evergreen

Aligned with Dr. Kim provides our patient form online so you may complete it in the convenience of your own home or office. When completed, you may fax us your printed and completed form or bring it with you to your appointment.

Personal Information

Please choose
Please choose

WHAT BROUGHT YOU INTO THIS OFFICE:
If you have no symptoms or complaints and are here for Optimal Health & Wellness Services, please skip to the “General Health History”.

Health Concerns - Please list your health concerns according to their severity

Rate of severity
Rate of severity
Rate of severity

Provocation/Palliation

Quality

Region/Radiation

Other doctors you have seen for this condition:

Doctor's details

Have you been "forced" or "felt the need" to make any "positive" changes in your life due to this pain, illness, condition, etc? (i.e., eat better, less alcohol or drugs, meditate or breathe more, less destructive sports, activities, etc.)

Is this condition interfering with any of the following:

Evergreen

8039 Line Avenue, Suite C, Shreveport, LA 71106

© 2023 All The Way Health - All Rights Reserved

8039 Line Avenue, Suite C, Shreveport, LA 71106

318-423-7379

© 2023 All The Way Health - All Rights Reserved

8039 Line Avenue, Suite C, Shreveport, LA 71106

318-423-7379

© 2021 All The Way Health - All Rights Reserved


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