Soft Tissue Rehab Michael J Covington, DC-PS
3907 Creekside Loop #100 Yakima, WA 98902

PATIENT INTAKE FORM

Full Name *

Date of birth

Phone *

Email *

Address *

City

State

Postal code

Height & Weight

Right or Left Handed

Occupation

Employer & Phone Number

Primary Doctor & Phone Number

Emergency Contact Name

Relationship to Patient & Phone Number

What is your primary complaint?

Treatments you've had thus far

I've received this treatment

List previous surgeries (including Orthopedic)

What activities does your condition interfere with?

Are you interested in finding a solution to your problem?

Yes