Ethos Human Regeneration Intake

Ethos Human Performance

Ethos Human Regeneration Intake Form
By coming here you have taken a big step toward improving and optimizing your health. Please fill out the following information as accurately as possible. Our intake form is thorough because we are thorough in our assessment and treatment. It is the only way to accurately determine how the various systems of your body are working together so that we can provide you with the personalized treatment that you deserve. It is our honor and pleasure to serve you.
How did you hear about Ethos Human Performance?*
Full Name*

First NameLast Name
Date

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Cell Phone Number*
Work Phone Number
Home Phone Number
Age
Years
Birth Date*

MonthDayYear
Date
Gender

MaleFemaleOther
Occupation
Marital Status

MarriedSingleDivorced
Spouse's Name (if applicable)
Spouse's Occupation (if applicable)
Date of Injury/ Diagnosis:*

MonthDayYear
Date
Have you ever been treated for the same condition?*

YesNo
Were you admitted to the hospital?

YesNo
Treating Physician:
If applicable, please upload medical history documents:

Browse Files

Cancelof
Describe injury/diagnosis:*
(aching, cramping, dull, sore, deep, sharp, shooting, stabbing, stinging, tingling, burning, numbness, radiating - if so, where?)
How did the pain first start? How did it start this time, if this is not the first time you've felt it?*
Sudden or gradual onset? Mechanism of injury?
How often does it bother you?

ConstantlyEvery nightEverydayEvery weekEvery monthOther
How long does it last once it's there?*

AlwaysMinutesHoursNo pattern
What specifically makes it worse?

Certain movements/activitiesTime of dayUpon wakingSleepingPositionNothing
Other therapies/remedies tried? Results?
Have you ever had any surgeries? Were they beneficial?
List any other health problems for which you are being treated:*
Do you have any pre-existing injuries that relate to this present injury?*

YesNo
If yes, please explain:
Current medications:
Activities of Daily Living

The objective of this section is to get a sense of what types of activities, movements, postures, positions, and exercise you engage in on a regular basis. This section is also intended to get a feel for the intensity and frequency with which you perform these activities.
Work Duties:
Household Duties:
Exercise, Activities, Hobbies:
Sleeping Position:
What do you believe caused, or is causing this condition?
On a scale of 1 - 10, how much effort are you willing to put in to achieve maximum healing?

12345678910
On a scale of 1-10, choose the level of stress you are experiencing on a regular basis:

12345678910
Medical History

ArthritisAllergies/Hay FeverAsthmaAlcoholismAlzheimer's DiseaseAutoimmune DiseaseBlood Pressure ProblemsBronchitisCancerCarpal Tunnel SyndromeCholesterol, elevatedChronic Fatigue SyndromeCirculatory ProblemsColitisDepressionDental ProblemsDiabetesDiverticular DiseaseDrug AddictionEating DisorderEpilepsyEmphesymaEnvironmental SensitivitiesEyes, ears, nose, throat problemsFibromyalgiaFood IntoleranceGastroesophageal RefluxGenetic DiseaseGlaucomaGoutHeart DiseaseInfectionIrritable Bowel SyndromeKidney or Bladder DiseaseLearning DisabilitiesLiver or Gallbladder Disease (stones)Mental IllnessMigraine HeadachesNeurological ProblemsObesityOsteoporosisPneumoniaSeasonal Affective DisorderSexually Transmitted DiseaseSkin ProblemsSinus ProblemsStrokeThyroid TroubleTuberculosisUlcerUrinary Tract InfectionVaricose VeinsOther
Medical (Men)

BPHInfertilityProstate CancerDecreased Sex DriveOther
Medical (Women)
Medical (Women)

InfertilityMenstrual IrregularitiesEndometriosisFibrocystic BreastsPMSFibroids/Ovarian TumorsBreast CancerVaginal InfectionsDecreased Sex DriveSTDC-SectionMenopauseSurgical MenopauseOtherPelvic Inflammatory Disease
Family Medical History

Arthritis, rheumatoidAsthmaAlcoholismAlzheimer's DiseaseCancerDepressionDiabetesDrug AddictionEating DisorderGenetic DiseaseGlaucomaHeart DiseaseLearning DisabilitiesMental IllnessMigraine HeadachesNeurological DisordersObesityOsteoporosisStrokeSuicideOther
Tobacco

YesNo
If yes, how many cigars or cigarettes a day?
Alcohol

YesNo
If yes, what type and how many drinks per week?
Exercise

Unable to Exercise5-7 days per week3-4 days per week1-2 days per week
Terms and Conditions
Release and Indemnification I hereby authorize Ethos Human Performance to provide any and all information, copies, or records to any clinic, physician, lawyer, insurance company, or workman's compensation fund as deemed necessary. A copy of this authorization shall be considered as valid as the original. I hereby authorize any physician to release any and all information and copies of all records to Ethos Human Performance as deemed necessary for treatment. A copy of this authorization shall be considered as valid as the original. I give permission that photographs and video footage may be taken of me or my X-rays, CAT, or MRI scans during the course of treatment at Ethos Human Performance. These photographs are strictly to be used for treatment planning, or education for other healthcare practitioners and will not be displayed anywhere else without my written permission. 24 Hour Cancellation Policy I understand that there is a 24 hour cancellation policy for scheduled appointments. Cancellation of a scheduled appointment must be made by calling Ethos Human Performance. Failure to cancel without the minimum notice will result in the full charge for the cancelled or missed appointment. Cancellation for Mondays and the day after holidays must be made on the prior business day during normal business hours. Payment for the entire amount of the scheduled appointment will be expected regardless of the patient's arrival time.
I agree to the above terms & conditions*

YesNo
Signature*

Clear
Should be Empty:

Ethos Human Performance

Activities of Daily Living

Medical (Women)

Terms and Conditions