Patient Intake Form

Please read before accessing the form below!

Attached below these instructions you will find the LINK to access our Patient Intake Form to be completed prior to your appointment with Dr. Orlando. Below are some instructions to help navigate through the Intake Form:

1. You will be asked the following information first:

– Name, General Information, Emergency Contact, Insurance Information, Employment Information, Referral Information

2. “REASON FOR VISIT”: If you have NECK Pain, UPPER BACK Pain and/or LOWER BACK Pain, you will list each complaint separately. Start with you Major Complaint/Reason first. Listing each complaint separately allows you to provide Dr. Orlando with detailed information about each spinal complaint.

MAIN REASON FOR VISIT: Choose from drop down menu (if you were not hurt at work or in an auto accident, you will most likely choose PAIN as your reason.)

BODY DIAGRAM: Click on area of the body for your 1ST COMPLAINT and any areas of radiating pain. For example, if your 1ST COMPLAINT is Neck Pain radiating into your head, arms or shoulders, you would click on all those areas as your 1ST COMPLAINT. A series of questions will follow. If you have additional Reasons/Complaints to report (i.e. LOW BACK Pain), it is IMPORTANT to answer YES to the VERY LAST question “DO YOU HAVE AN ADDITIONAL CONDITION?” Answering YES to that question will then prompt you for “SECOND REASON FOR VISIT”. You will continue this process until you have provided all your Reasons/Complaints.

3. You will be asked some additional information:
– Current Health
– Personal And Family History
– Work Social Habits

Please do not hesitate to contact our office with any questions.