Laser Therapy New Patient Registration

First Name *

Middle Name *

Last Name *

Date of Birth *

Phone *

Email *

Address *

City *

State *

Postal code *

City and State *

Marital Status *

Single
Married
Divorced
Widower/Widowed
In a domestic partnership
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Occupation

How Did You Hear About Us?

Family Member

Co-Worker

Friend

Doctor Referral

Facebook

Google

Close to home/work

Other

Name of Person Who Referred You:

EMERGENCY CONTACT INFORMATION

Full Name *

Relationship:

Emergency Contact Phone Number *

REASON FOR VISIT

What health concern brings you to our office?

When did this problem begin?

Please Explain:

Is this visit related to any of the following:

Job

Sports

Auto

Fall

Chronic Discomfort

Home Injury

Other

Will this visit be a part of a Worker's Compensation claim?

Yes

If this injury is the result of a motor vehicle accident, have you notified your insurance company?

Yes

On a scale of 0 to 10, 0 being no pain, 10 being the worst pain you have ever had, where would you rate your current level of pain?

0 (I have no Pain)

1 (Minimal)

2 (Mild)

3 (Uncomfortable)

4 (Moderate)

5 (Distracting)

6 (Distressing)

7 (Unmanageable)

8 (Intense)

9 (Severe)

10 (Unable to Move)

If job related, have you made a report of your accident to your employer?

Yes

Has this problem gotten better, worse, or stayed the same since it began?

Gotten Worse

Stayed Constant

Comes and Goes

Gotten Better

Does this condition interfere with:

Work

Sleep

Daily Routine

Other Activities

How would you describe your discomfort?

Sharp

Shooting

Aching

Dull

Numbing

Pins and Needles

Tight

Sore

Throbbing

Other

Other:

PAIN/DISCOMFORT DIAGRAM

Please mark the boxes below according to where you feel pain.

Mark whichever number(s) correlates to the area(s) of complaints on the graphic above

1 (R Head)

2 (L Head)

3 (Neck)

4 (R Chest)

5 (L Chest)

6 (Upper R Arm)

7 (Upper L Arm)

8 (R Arm)

9 (Left Arm)

10 (R Hand)

11 (L Hand)

12 (R Ribs)

13 (L Ribs)

14 (R Stomach)

15 (L Stomach)

16 (Groin)

17 (R Thigh)

18 (L Thigh)

19 (R Leg)

20 (L Leg)

21 (R Foot)

22 (L Foot)

23 (R Head Back)

24 (L Head Back)

25 (Neck Back)

26 (R Shoulder)

27 (L Shoulder)

28 (R Upper Arm Back)

29 (L Upper Arm Back)

30 (R Arm Back)

31 (L Arm Back)

32 (R Hand Back)

33 (L Hand Back)

34 (R Mid Back)

35 (L Mid Back)

36 (R Lower Back)

37 (L Lower Back)

38 (R Buttocks)

39 (L Buttocks)

40 (L Thigh Back)

41 (R Thigh Back)

42 (R Leg Back)

43 (L Leg Back)

44 (R Foot Heel)

45 (L Foot Heel)

Contradictions/Precautions

Prior to considering laser therapy for you, it is important for the doctor to know of any health conditions that are contraindicated or precautionary to this therapy. Please review the list below and check off any/all conditions that pertain to you.

Absolute Contraindications to Laser Therapy: (Please check all that apply.)

Treatment for cancer with last 2 years

History of leukemia

HIV positive history

Take anticoagulant medication (blood thinners)

History of laminectomy

Current MERSA or STAPH infection

Seizure disorder triggered by light

Implanted neurological stimulation device

Current shingles rash

Pacemaker/ICD implanted device

Have hemorrhagic diatheses

Current tumor(s)

Precautionary Conditions: (Please check all that apply.)

Tattoos in area of treatment

Currently pregnant

Metal piercings in area of treatment

History of cancerous skin lesions

Steroid injection in area of treatment within the last 2 weeks

Take medications that increase sensitivity to light

By signing below, I certify that I have checked any and all of the above listed absolute contraindications and precautionary conditions that apply to me. If I have not checked any of the above boxes, I certify that I do not have any of the absolute contraindications or precautionary conditions listed. I also agree to immediately inform the doctor of any changes to my status of any of the above indicated absolute contraindications and/or precautionary conditions.

I attest that all information provided on this form is accurate to the best of my knowledge as of the date of this form, and I clearly understand and agree that all services rendered to me are charged directly to me, and that I am personally responsible for all payment.

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Patient Email: *