Shockwave Intake Form
Connecting the Disconnected Since 2008
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Sex
Male
Female
Marital Status
Single
Married
Divorced
Widowed
Spouse's Name
Number of Children
Emergency Contact Name
*
Emergency Contact Relationship
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
How did you hear about Core Health?
Please Select
Friend or Family
Google
Facebook
Instagram
Pride of Dakota
Community Event
Other
Daily Pain Level Rating
Best
1
2
3
4
Worst
5
1 is Best, 5 is Worst
Primary Complaint:
*
Where is your primary complaint located?
*
Head/Neck
Shoulders
Arms
Back
Hips
Legs
Feet
Other
What are you wanting to get back to doing that you are unable to currently do?
*
Medications:
Medications:
Medications:
Medication List Upload
Browse Files
Drag and drop files here
Choose a file
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Please describe how the injury, pain or discomfort originated:
Please describe your pain or discomfort:
Choose a frequency you experience pain/symptoms from this condition:
Always
Hourly
Daily
Occasionally
Does this condition interfere with any of your daily activities or routines?
Yes
No
Has this condition affected your sleep?
Yes
No
Have you received any treatment for this injury/condition?
Yes
No
(Female Only) Are you pregnant, or have you had signs of pregnancy?
Yes
No
(Female Only) Are you planning to get pregnant in the next 12 months?
Yes
No
Health Concern
*
Broken Bones
Major Strain/Sprain
Eating Disorder
Been Hospitalized
Had Surgery
Auto Accident
Been Struck Unconscious
Had A Stroke or Heart Issue
Other
Any Checked Boxes Above? Explain here:
Family Health History:
Family Health History:
Health Problems
*
Signature
Clear
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