Basic Information *Note: If you are having trouble using our online form. You can just simply download the pdf here
Basic Information
Choose your preferred location:
First Name:
Last Name:
Middle Initial:
Date of Birth:
Gender:
E-mail:
Complaint
Complaint
What is the complaint that brought you here?
When approximately did this complaint begin?
Has it recently worsened?
If "Yes", When?
What caused this complaint?
What activities are you unable to do, or do without pain?
Are you afraid of physical activity?
If “yes”, why?
What makes this complaint better?
What makes this complaint worse?
Does this complaint affect your stress level, comfort or mood?
Yes
What have you felt in the past week, including today?
What symptoms are you experiencing with this complaint?
 
How frequent are the symptoms experienced?
How much pain are you experiencing? (Scale 1-10)
None Mild Moderate Severe Worst
What tests have you had for this complaint?
What treatment have you had for this complaint?
 
What is your occupation
Work Status:
Last Date Worked:
Body Diagram
Body Diagram

"Please click on the areas in the body diagram where you experience pain or aches"



 
General Health
General Health
Please check all medical conditions that you have, or have had.
 
Please check all of the following items that currently or have previously applied to you.
 
Please list all scars & surgeries.

(Maximum characters: 400)
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Previous and Current Joint/Muscle/Bone Injuries/Pain:

(Maximum characters: 400)
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Please list allergies:
Please list medications, vitamins and/or supplements you are currently taking:
Are you currently receiving psychological or social services?
Do you need help finding services?
Your primary physician’s Name:  
What goals do you want to achieve through treatment?
How many hours of sleep do you get?
Do you have trouble falling asleep or staying asleep?
How many days per week do you exercise?
What type of exercise do you do?
Signature
Signature
How did you hear about us?
 
We are interested in who our clients are. Please tell us if you are a student, teacher, or administrator.
If so, which school?

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Finalize
Finalize

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