Medical Intake Form

Name*

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

MonthDayYear
Date
Please mark the area of injury or discomfort on the chart below with an x or circle the area. *
Check the pain description that matches your symptoms the most from the list below*

NumbnessAchingBurningPins/NeedlesStabbingShootingOther
What percent of the day do your symptoms affect you? *
Total Hours
Please rate your current pain level by selecting it on the scale below with "0" meaning no pain and "10" meaning unbearable pain.*

1

2

3

4

5

6

7

8

9

10

1 is No pain, 10 is Worst pain
Single Assessment Numeric Evaluation (SANE)
Please rate your ability to use your injured body part in your normal daily activities. 0% means you can do nothing, while 100% means you can do everything with restriction.
Please rate your ability to use your injured body part in your sport/exercise activities. 0% means you can do nothing, while 100% means you can do everything with restriction.
Patient-Specific Fundamental Scale (PSFS):

Please choose three activities and rate your ability to perform them with 0, meaning you are unable to perform and 10, you can perform without restriction
Activity 1
Rating 1

0

1

2

3

4

5

6

7

8

9

10

0 is Unable to Perform , 10 is Can perform without restriction
Activity 2
Rating 2

0

1

2

3

4

5

6

7

8

9

10

0 is Unable to Perform , 10 is Can perform without restriction
Activity 3
Rating 3

0

1

2

3

4

5

6

7

8

9

10

0 is Unable to Perform , 10 is Can perform without restriction
Please list any pre existing medical conditions you are currently diagnosed with
Please list any medications you are currently taking (prescription, over the counter, supplements)
Should be Empty:

Single Assessment Numeric Evaluation (SANE)

Patient-Specific Fundamental Scale (PSFS):