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Patient Name
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Date Of Birth
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Address
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Phone
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Email
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City
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State
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Zip
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Gender
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Emergency Contact
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Name
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Phone
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Occupation
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Referred By
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SSN
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Marital Status
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Employer
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Employer Address
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Primary Care Physician
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Name
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Phone
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What is the primary reason for this visit:
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Are you under the care of a physician for this condition?
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Diagnosis:
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How long have you had this condition:
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Have you tried any other treatments:
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What makes it worse:
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What makes it better:
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Is there anything else you would like to address in addition to your primary reason for seeking treatment:
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Where are your current areas of pain?
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Rate your current level of pain (0= no pain; 10= unbearable pain):
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In the past week, how much has your pain interfered with daily activities? - 0= no interference; 10= unable to carry on activity
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Do you have any additional comments regarding your pain level and how it is affecting your life?
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How often are these symptoms present?
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Other(s)
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How has this condition impacted your life?
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Other(s)
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Have you ever received any of the following therapies and for what condition?
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Other(s)
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Please describe your progress from these therapies
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What would be different or better without this health problem?
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How would you describe your overall state of health?
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What is your personal goals for optimal health and well-being?
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What are your potential barriers for achieving your goal?
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How important is it for you to resolve your health concerns?
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Are you prepared to make appropriate lifestyle changes that may be necessary in order to achieve your health and wellness goals?
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Patient Medical History
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What is your current weight?
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What is your height? - Please fill in Feet / Inches
/
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Are you pregnant?
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How many months?
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If pregnant, OB-GYN doctor’s name & phone #:
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Do you have a pacemaker?
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Do you have any metal (rods, pins, etc) in your body?
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Location:
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Are you taking any blood thinners?
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Please list any allergies:
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Hospitalisations/Surgeries - Reasons & Date
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Injuries [Type, Date & Outcome]
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Family Medical History
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Please indicate whether a BLOOD RELATIVE has had any of the following:
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Other(s)
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Dietary Information
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Please indicate what you eat on a regular basis:
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Other(s)
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Exercise habits:
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Alcohol consumption (# of drinks per week)
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Caffeine consumption (# of beverages per day)
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Tobacco use (# of cigarettes per day)
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Medications/Vitamins/Herbs
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Review of Systems
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Please indicate whether YOU have had any of the following:
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General:
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Skin/Hair/Nails:
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Cardiovascular:
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Head/Eyes/Ears/Nose/Throat/Respiratory:
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Gastrointestinal:
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Bowel Movements
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Frequency
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General - Off if 'Not' Applicable
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Psychological:
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Musculoskeletal:
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Neurological:
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Genitourinary:
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Gynaecological: - Off if 'Not' Applicable
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Age first period
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Days of flow
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Length of cycle
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Date of last period
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Number of pregnancies?
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Number of Live births?
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Number of Miscarriages?
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Number of Abortions?
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Menopause age
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General:
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