Patient Intake Form

Patient Information

Date

Name

First NameLast Name

Age

Phone

Email

example@example.com

What Brings You In Today?

How Did You Hear About Us?

Place X's on the chart where you are feeling pain. If the pain is starting in one location and ending in another, draw a line showing how the pain travels.

Choose a number from the pain scale and describe the pain (i.e. aching, sharp, shooting, etc during the following activities:

Sitting

Standing

Walking

Daily Activities

Sleeping

Is This Pain From an Injury?

YesNo

If yes, give a brief description of the injury and diagnosis

Has this pain been diagnosed by a doctor?

YesNo

If yes, please list the type of doctor and diagnosis given

Have you tried any other treatments or remedies?

YesNo

If yes, give a brief description of the treatment or remedy

Do you have an active hemorrhage?

YesNo

Do you have uncontrolled Blood Pressure?

YesNo

Do you have a Pacemaker or Implantable Defibrillators?

YesNo

Do you have a Blood Clot?

YesNo

Are you currently pregnant?

YesNo

Do you have a high risk for an aneurysm?

YesNo

Have you been diagnosed with cancer?

YesNo

Do you have Tinnitus?

YesNo

Do you have a coagulation disorder?

YesNo

Have you been diagnosed with hemorrhagic diathesis?

YesNo

Have you been diagnosed with a serious infectious disease?

YesNo