Your Information:

First Name *

Last Name *

Phone *

Email *

General Health

How would you rate your overall health? *

Poor

Fair

Good

Excellent

Which areas of life contribute to your overall stress? *

Physical

Emotional/Mental

Nutrition/Diet

Relational

Work

Other

How would you rate your sleep? (quality and duration) *

Poor

Fair

Good

Excellent

How much intentional activity do you average each day? *

Less than 15 min

15-30 min

30-60 min

Greater than 1 hour

Primary Concern

How did this issue begin? *

What tests/treatments have you had for this problem? *

X-ray

MRI

CT Scan

Myelogram

EMG

Other Physical Therapy

Other Doctor

None

What makes the pain worse? *

What makes your pain better? *

On a scale of 1-10, one being hardly any pain and ten being unbearable, how would you rate your pain? *

1

2

3

4

5

6

7

8

9

10

Select any that apply *

Bowel/Bladder changes

Numbness/Tingling

Personal History of Cancer

Fever, chills, and/or night sweats

Unexplained weight loss >10 lbs

Double/blurry vision

Dizziness

Passing out

Trouble speaking

Trouble swallowing

None

Past Medical:

Have you had surgery on areas not related to your primary concern? Where? *

List any current medications: *

Cardiovascular *

High Blood Pressure

Low Blood Pressure

CHF

Heart Attack

Phlebitis/Vericose Veins

Stroke/CVA

Pacemaker or Similar

Heart Disease

Family History

None

Respiratory *

Chronic Cough

Shortness of Breath

Bronchitis

Asthma

Emphysema

Family History

None

Goals:

If we could help you accomplish/do one thing, what would it be? (DREAM BIG) *

I agree to receive emails and SMS communications Results Rehab.