Patient Medical History and Intake Form

Patient Medical History and Intake Form

Please complete this form to the best of your ability with the fullest level of detail possible so that we are best able to address your needs. If you have any questions about anything on this form please reach out to us at info@enduranceunleashed.com or call 919-516-9050
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Date of Birth*

MonthDayYear
Date
Referring PhysicianFriend/Family MemberSearch Engine (Google, Yahoo, Bing)Social Media (Facebook, Youtube, Intstagram)Event/WorkshopOther
Who is your referring Physician/Specialist (if any)?
Very recently - a few days agoA few weeks agoA few months agoUp to and over a year agoUnsure - it has been that longLooking more for prevention - Nothing hurts
I have had a fever within the past three monthsI have had bowel and bladder issues within the past 3 monthsI have had falls, motor vehicle accidents, or ER visits within the past 3 monthsI have had a fracture within the past 3 monthsI have had a recent change in medication within the past 3 monthsI have not had ANY of these things happen within the past 3 months
What hurts or why are you filling out this form?*
How did this condition start?*
I can't do certain things I love to doI am avoiding activity and not pushing myself because I am unsure if it is safe toI am doing everything - it just hurts or it is annoyingIt is not impacting my life right now but I am afraid it will in the future
Why are you looking to take care of this issue right NOW? (please be as detailed as possible so we are best able to address your needs)*
Some value - I do not feel my condition is not that badAmazing value - I am in pain and would like this to be goneExceptional value - I am avoiding doing the things I love and it really sucksPriceless - if what I have is gone despite everything I have tried - it would be AMAZING!!Other
What goals/expectation do you have for your current condition? What would you like to get back to doing? (please be as detailed as possible)*
PoorFairGoodVery goodExcellent

What has your pain level been over the past 24 hours?*

	1	2	3	4	5	6	7	8	9	10

1 is No pain, 10 is TAKE ME TO THE HOSPITAL NOW!!!

What has your pain level been over the past week?*

	1	2	3	4	5	6	7	8	9	10

1 is No pain, 10 is TAKE ME TO THE HOSPITAL NOW!!!

Constantly (75-100%)Frequently (51-74%)Occasionally (26-50%)Intermittently (0-25%)No pain - Just want prevention
General PractitionerChiropractorEMG/NCVMassage TherapyNeurologistOrthopedistPodiatristX-rays/CT Scan/MRIOccupational TherapyPhysical TherapyEmergency RoomOther
AsthmaBronchitis/EmphysemaHeart AttackChest pain/Angina/CADOther heart troubleGoutHigh Blood PressureShortness of BreathDiabetesThyroid/GoiterCancer/chemotherapy/radiatiomWeakness (unexplained)Dizziness/FaintingInfectious DiseasesUnintended weight lossOsteoporosisJoint replacementHeadachesEmotional problemsNumbness/tinglingVision/Hearing DifficultiesDo you have a pacemaker?Epilepsy/seizuresAllergiesAnemiaArthritisPins/Metal ImplantsSleeping problemsDepressionBlood clot/emboliPregnantStroke/TIAConcussion historyI HAVE NONE OF THESE
Please explain any of the above "Yes" answers or describe any medical issues in detail below
Please verify that you are human*
Signature*

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I AGREE
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