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Feel free to answer in your own words. If you do not have anything to add, leave the section blank. Send the form using the clickable SEND button at the end. Information is confidential.
Name *
Birth year *
I'm: EmployedUnemployedStudentRetired
Description of possible employment.
In your own words, describe the reason for seeking treatment, its duration, the contributing factors, and how it may affect your mobility and sleep. You may include multiple reasons if applicable.
Please feel free to provide specific details about any previous injuries related to the reason for seeking treatment, including what happened and when.
Please include specific details regarding the onset and progression of the possible medical condition related to the reason for seeking treatment.
Please include specific details regarding possible previous or upcoming surgeries related to the reason for seeking treatment.
Please include specific details regarding possible medications related to the reason for seeking treatment.
Please provide specific details about any possible previous imaging studies related to the reason for seeking treatment. You may bring the report with you to your appointment.
Health condition ExcellentGoodSatisfactory
Please provide type of possible exercise and frequency per week.
Possible previous treatments related to the reason for seeking treatment. Please provide additional details about the type of treatment and its effect on the symptoms.