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HOME
HOME
OUR STORY
WHO WE ARE
CAN WE HELP
WHAT TO EXPECT
CONTACT
HOME
Please complete the form below
Name
*
First Name
Last Name
Have you been hospitalized for this injury/condition?
*
Yes
No
If yes please explain reason for hospitalization
History of Complaint
Is your injury/condition related to an auto accident or work related injury?
*
Yes
No
If yes, please explain.
How did the injury occur (examples: insidious onset, fall, injury)?
In your words, how would you describe the pain? (examples: ache, burning, numbness)
*
On a scale from 0 to 10 with 10 being the "worst pain you have ever felt" and 0 being no pain, how would you rate your discomfort?
Date of Onset (when did it begin)
*
MM
DD
YYYY
How often do you experience the pain?
*
Constant
On/off throughout the day
Comes and goes throughout the week
What time of day is the problem the worst?
*
AM
Mid-day
PM
Late PM
No specific time of day
Does the pain/discomfort radiate into your extremities?
*
Yes
No
If yes please explain:
Second (area of) Complaint (if present)
How would you describe the pain/discomfort?
On a scale from 0 to 10 with 10 being the "worst pain you have ever felt" and 0 being no pain, how would you rate your discomfort?
Date of Onset
MM
DD
YYYY
How often do you experience the pain/discomfort?
Constant
On/off throughout the day
Comes and goes throughout the week
What time of day is the problem the worst?
AM
Mid-day
PM
Late PM
No specific time of day
Does the pain/discomfort radiate into your extremities?
Yes
No
If yes please explain:
Do you have more than two complaints?
*
If yes, we will discuss in-person with the doctor
Yes
No
In the past 6 months have you experienced any of the following health challenges? Please check all that apply.
General
Fatigue
Fever(s)
Unexplained weight loss
Insomnia
Ears, Eyes, Nose & Throat
Visual changes
Hearing loss
Sore throat
Trouble swallowing
Nasal congestion
Ear pain
Respiratory
Prolonged cough
Unable to catch breath
Wheezing
Snoring
Cardiovascular Issues
Irregular heartbeat
Racing heart
Chest pain
Swelling of legs or feet
Shortness of breath
Musculoskeletal
Joint pain
Muscle pain
Neurologic
Headaches
Dizziness
Difficulty walking
Numbness or tingling in face
Seizures
Gastro-Intestinal Issues
Abdominal pain
Constipation
Diarrhea
Gas
Heartburn
Nausea
Vomiting
Genitourinary
Painful urination
Bloody urine
Increased urination
Leaking urine
Females Only Section
Ionizing radiation can be hazardous to an unborn child
*
To the best of my knowledge I am not pregnant and the doctor has my permission to perform an x-ray evaluation.
I am currently, pregnant and therefore I am unable to receive ionizing radiation at this time.
Are you trying to become pregnant?
Yes
No
If yes, have you had trouble conceiving?
Yes
No
Social History
Do you smoke (cigarettes, cigars, pipe)?
*
Daily
Weekends
Occasionally
Never
Do you consume alcoholic beverages?
*
Daily
Weekends
Occasionally
Never
Do you use marijuana?
*
Daily
Weekends
Occasionally
Never
Do you use drugs recreationally (Example: cocaine, methamphetamines)?
*
Daily
Weekends
Occasionally
Never
If yes, please list which drugs you use and how often.
Exercise level (number of times per week 0-7 days)
What position do you typically sleep in?
Back
Stomach
Side
Unsure
List all medications currently (in the space provided). And please give the reason for use (not all medications are prescribed for the symptom(s) or condition(s) they were approved for) and the length of time using:
Thank you! One of our team members will be contacting you shortly.
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