Personal Information

Name:      Leisure Activities:
Occupation:       Currently working full duty? Yes No
Do you have a latex allergy? Yes No

Pain Level

Please rate your pain intensity (0=no pain, 10=worst pain imaginable)
Most:   Least:   Current:

Please describe your pain (select):
Numbness       Pins & Needles       Burning       Aching       Stabbing       Grinding       Stiffness      
Cramps       Throbbing       Dull       Constant       Intermittent       Other

About Your Pain

When did your pain begin?
What makes your pain worse?
What make your pain better?

Is this injury related to (select):
Work       Motor Vehicle Accident       Recurrent (prev. injury)       Recreational Injury      
Athletic Injury       Fall       Other

Select any of the following whose care you are under:
Medical Doctor      Osteopathic Physician      Dentist      Psychiatrist/Psychologist      
Physical Therapist      Chiropractor

For what reason are you under their care?

Medical History

Have you Ever Been Diagnosed with the Following Conditions?

Depression        Thyroid Problems        Arthritis        Asthma        High Blood Pressure        
Rheumatoid Arthritis        Anemia        Hepatitis        Circulation Problems        Stroke        
Tuberculosis        Emphysema/Bronchitis        Kidney Disease        Multiple Scleros      
Chemical Dependency        Epilepsy        Heart Problem        Cancer

Please List any surgeries or any other conditions for which you have been hospitalized including the approximate date:

Please list any significant injury (strain, sprain, dislocation, etc.) for which you have been treated including the date:

Has anyone in your immediate family (Parents, Brothers, Sisters) ever been treated for any of the following? (Select)

Diabetes      High Blood Pressure      Chemical Dependency      Tuberculosis      
Kidney Disease      Cancer      Heart Problems      Arthritis      Epilepsy      
Anemia      Headaches      Mental Illness      Stroke      Thyroid Problems

Which Over the Counter Medications have you taken in the last week?

Asprin      Laxatives      Antacid      Tylenol      Decongestants      Vitamins      
Advil/Motrin/Ibuprofen      Antihistamines      Supplements


Please list any prescription medications you are currently taking (including pills, injections, and/or skin patches):

General Questions

How many cups of caffeinated coffee or caffeine containing beverages do you drink per day?

Do you smoke? Yes No
If Yes, How many packs per day?      How many years have you smoked?

How many days per week do you drink alcohol?
If one drink equals one beer, glass of wine or shot, how much do you drink at an average sitting?

Have you recently noted:

Weight Loss/Gain      Fatigue      Fever/Chills/Sweats      Nausea/Vomiting      
Weakness      Numbness or Tingling

Do you have any allergies?

Please describe your goals for therapy: