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Please fill out the form below prior to your first visit. This will allow us to provide immediate care for you upon arrival and save you from having to show up much earlier to fill it out in our clinic.

First Name (required)

Last Name (required)

Date of Birth (required: mm/dd/yyyy)

Address (required)

Telephone (required)

Diagnosis, Injury or Condition you are seeing us for (required)

Date of Condition/Injury (required: mm/dd/yyyy)

Referring Physician (if applicable)

What are your current symptoms and have you experienced them in the past? (required)

On a scale from 0-10 (0 = NO PAIN and 10 = WORST PAIN) in the last week, please mark your pain level as follows:
LOWEST:012345678910
HIGHEST:012345678910
CURRENT:012345678910

Please list all activities, positions, and anything else you have noticed that makes your symptoms BETTER and what makes them WORSE? (required)

Please answer yes or no if you have any of these conditions:

Alzheimer’s	YesNo
Cardiovascular Disease	YesNo
Groin Numbness	YesNo
Stroke	YesNo
Current Infection	YesNo
Diabetes Type 1	YesNo
Diabetes Type 2	YesNo
Fibromyalgia	YesNo
Suspected Fracture	YesNo
High Blood Pressure	YesNo
Hepatitis B or C	YesNo
History of Cancer	YesNo
Huntington’s	YesNo
Immunosuppression	YesNo
Lupus	YesNo
Muscular Dystrophy	YesNo
Obesity	YesNo
Osteoarthritis	YesNo
Parkinson’s	YesNo
Rheumatoid Arthritis	YesNo
Traumatic Brain Injury	YesNo
Other

In the last month have you done any of the following?

Seen a medical professional, a physical therapist, or any other health care provider?
YesNo
If yes, please explain:

Had an X-ray, MRI, CAT-Scan, or any other tests performed?YesNo
If yes, please explain:

Had any surgeries, procedures, or treatments performed?YesNo
If yes, please explain:

What medications are you currently taking?

Please list any allergies you have:

In the last 2 weeks have you experienced any of the following?

Fever/Chills/Sweating	YesNo
Numbness/Tingling	YesNo
Night pain where you are unable to fall back asleep	YesNo
UNEXPLAINED weight loss	YesNo
Changes in bowel or bladder function	YesNo

In the last 6 months have you fallen?YesNo
If so, can you explain why?

Is there any other details you can share about the nature of your current condition/injury? Please note, that this will help us provide the most effective treatment strategy for you so we can get you better, faster:

Intake Form

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Please answer yes or no if you have any of these conditions:

In the last month have you done any of the following?

In the last 2 weeks have you experienced any of the following?

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