Shockwave Intake Form

Shockwave Intake Form

Connecting the Disconnected Since 2008
How did you hear about Core Health?*
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Sex

MaleFemale
Marital Status

SingleMarriedDivorcedWidowed
Spouse's Name
Number of Children
Emergency Contact Name*
Emergency Contact Relationship*
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Primary Complaint:*
Secondary Complaint:
Tertiary Complaint:
Please describe the origin of each complaint:*
Do any of your complaints interfere with any of your daily activities, routines &/or have you had to recently or in the past alter how you do something?*

YesNo
Explain each complaint by how often, what time of day &/or what are you doing when you experience any issue:*
Daily Pain Level Rating

1

2

3

4

5

1 is Best, 5 is Worst
Have any of your complaints listed above impacted your sleep?

YesNo
If Yes, please explain:
Have you received any treatment for any of the complaints listed above?

YesNo
If Yes, please explain:
Have you received a cortisone injection &/or an injection of any kind within the last 30-days? *
If Yes, please explain:
(Female Only) Are you pregnant, or have you had signs of pregnancy?

YesNo
(Female Only) Are you planning to get pregnant in the next 12 months?

YesNo
Additional Health Concerns*

Broken BonesMajor Strain/SprainEating DisorderBeen HospitalizedHad SurgeryAuto AccidentBeen Struck UnconsciousHad A Stroke or Heart IssueOther
Any Checked Boxes Above? Explain here:
Medication List Upload

Cancelof
Please provide a detailed (name, dosage, reason) list of all medications you are currently taking:
Family Health History:
Family Health History:
Signature
Should be Empty: