First name
Last name
Email
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Phone Number
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Home address
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General Practitioner Details (in case of emergency)
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Contact name, number and address of second person in case of emergency
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What sporting or other physical activities do you participate in?
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Describe the problem(s) for which you seek therapy:
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Explain how problem(s) occurred:
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Have you ever had the problem(s) before?
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How are you taking care of the problem(s) now?
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What makes the problem(s) worse?
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What makes the problem(s) better?
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What functions could you perform before, that now you are unable to do?
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What are your goals for therapy?
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If you have pain, is it constant (i.e. 24 hours per day, always present) or intermittent (it comes and goes)?
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Please Select
Constant
Intermittent
If you have pain, what is your pain level at best?
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Please Select
0 - No pain
1
2
3
4
5
6
7
8
9
10 - Worst possible pain
Pain level at worst
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Please Select
0 - No pain
1
2
3
4
5
6
7
8
9
10 - Worst possible pain
Does your pain trouble you from falling asleep?
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Please Select
yes
no
not applicable
I don't know
Does your pain wake you at night?
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Please Select
Yes
No
Not applicable
I don't know
Have you received X-rays, MRI, CT scan, Bone Scan, etc. for this problem? If so, what were the results
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Please provide detail of previous injuries or surgery.
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Are you aware of any physical reason why you should not receive treatment?
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Please Select
Yes
No
If yes, please tell me what it is.
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Nausea/Vomiting
1
Unusual weakness
1
Bleeding
1
Chest pain
1
Difficulty sleeping
1
Dizziness spells
1
Visual problems
1
Difficulty walking
1
Shortness of breath
1
Loss of appetitie
1
Pain at night
1
Heart palpitations
1
Joint pain or swelling
1
Incontinence
1
Unexplained weight changes
1
Currently pregnant
1
Hearing problems
1
Fever/chills/sweat
1
Productive/chronic cough
1
Fatigue or myalgia
1
None of the above
1
Diabetes (I/II)
1
Pacemaker
1
Backpain
1
Broken bones
1
Blood clots
1
Heart disease
1
Stroke (TIA or CVA)
1
Circulation problems
1
Respiratory Problems
1
Rheumatoid arthritis
1
High blood pressure
1
Seizures
1
Osteoporosis
1
Depression
1
Thyroid problems
1
Cancer
1
Metal Implants
1
Stomach ulcers
1
Asthma
1
Kidney problems
1
None of the above
1
During the past month have you been feeling down, depressed, or hopeless or bothered by having little interest or pleasure in doing things?
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Please Select
Yes
No
Please list any other medical conditions that you currently have or have previously been diagnosed with.
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Please list any medications you are taking.
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Please select one answer about your smoking history
*
Please Select
Current Smoker
Ex-smoker
Non-smoker
How much water do you drink per day?
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Please Select
Less than 500 millilitres (ml)
500 ml to 1 litre (L)
1 to 1.5 L
1.5L to 2L
2 to 2.5 L
2.5L to 3 L
Greater than 3 L
How many hours of sleep do you get each night?
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What is your occupation?
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What do you most want out of your session with me?
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