Cryotherapy for Veterans
Intake Assessment
Full Name
*
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Gender
Please Select
Male
Female
Other
Best Contact Number
Please enter a valid phone number.
Can messages be left at this?
Yes
No
Email
*
Emergency Contact
Relationship
Emergency Contact#
Referral Information
How did you hear about Cryotherapy for Veterans? (Please check all that apply)
A Veteran's Organization
Another Patient
Flyer
Internet
Radio
Other
Presenting Problem
What is your primary concern or reason for today's visit?
Have you ever had a Whole Body Cryotherapy session?
Yes
No
Military Service
Have you served in the military?
Yes
No
What is your military status?
Active Duty
National Guard/Reserve
Retired
Branch of Service
Dates of service
First Responder
Are you a first responder (e.g. paramedic, doctor, nurse, police officer, fire fighter, etc.)?
Yes
No
Medical History
Do you have any following medical conditions?
High Blood Pressure
Yes
No
Heart Conditions
Yes
No
Raynaud's Syndrome
Yes
No
Respiratory Conditions (i.e., asthma)
Yes
No
Do you have a pacemaker?
Yes
No
Are you pregnant (females only)?
Yes
No
Any other medical condtions
Do you have headaches or migraines?
Yes
No
How many headaches/migraines do you have a month?
0
1-3
4-6
7+
Date
-
Month
-
Day
Year
Date
Are you prescribed any medications?
Yes
No
Please list
History of surgeries/hospitalizations
Pain History
Do you have pain?
Yes
No
Please rate the following
1 - 3
4 - 6
7 - 10
Current level of pain
Average level of pain in the past 2 weeks
Worst level of pain in the last 2 weeks
Where is your pain located?
When did your pain start?
Is your pain related to an injury or illness?
Yes
No
Please explain
Are there things that make your pain worse? Please list
Are there things that help reduce your pain? Please list
Are you prescribed pain medication(s)?
Yes
No
Please list
How often do you take pain medication
1-2x weekly
3-4x weekly
5-7x weekly
Multiple times a day
Mental Health History
Over the past 2 weeks, please indicate how much you were distressed by the following
Not at all
Moderately
Extremely
Feeling depressed/blue
Anxiety/Tension/Panic
Thoughts of hurting self/others
Grief/loss
Traumatic events or abuse
Eating disorder issues
Over the past 2 weeks, please indicate how much you were distressed by the following
Not at all
Moderately
Extremely
Substance Abuse
Other Addictive/Compulsive behavior
Employment
What is your employment status?
Full time
Part time
Medical leave
Student
Retired
Disabled
Other
Please explain
Lifestyle
Over the past 2 weeks, how many hours did you sleep per night on average?
1-2
3-4
5-6
7+
Do you exercise?
Yes
No
How many days per week do you excercise?
1-2
3-4
5+ days
What are your hobbies or things you enjoy?
Treatment Goals
What is your goal(s) for treatment?
Reduce pain or inflammation
Improve mood
Decrease reliance on pain medication
Improve sleep
Decrease anxiety
Faster recovery
Management of chronic illness
Support healing of an injury
Reduce brain fog
Other
Any other information
Patient Health Questionnaire (PHQ-9)
Over the Last 2 weeks, have you felt bothered by any of the following problems?
Not at all
Several Days
More than half the days
Nearly every day
Little interest or plessure in doing things
Feeling down, depressed or hopeless
Trouble falling asleep or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself or that you are a failure or have let yourself or family down
Trouble concentrating on things, such as reading the newspaper or watching television
Moving or speaking so slowly that other people could have noticed. Or the opposite-being so fidgety or restless that you have been moving around a lot more than usual
Thoughts that you would be better off dead, or of hurting yourself in someway
If you checked off any problem, how difficult have these problems made it for you to do your work, take care of the things at home, or get along with other people?
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
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