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Street Address Line 2
State / Province
Postal / Zip Code
Date of Birth
Lifestyle and Medication Information
How often do you exercise
Not at all
1-2 times a week
3-4 times a week
5 or more times a weeks
If you exercise, what type of exercises do you do? (cardiovascular, weight training, swimming, etc.)
Average number of hours you sleep:
Do you sleep soundly at night?
If no, please explain in more detail
How often do you take aspirin, Advil, or Tylenol?
Enter how many days a week you take this medicine
Do you take any vitamin/mineral supplements or herbal supplements?
If you are a woman, are you currently on any hormone replacement therapy?
Please list and describe what they are for
If yes, please explain:
Are you pregnant, or is there a possibility that you are pregnant?
If you have any known allergies/sensitivities to any foods, medications, airborne particles, please list them below:
Have you ever been diagnosed with any type of tumor or cancer
If yes, please explain:
If you have ever undergone any surgeries, pllease list with dates:
Please list any injuries or accidents you have been treated for with dates:
Do you suffer from now or in the past five years any of the following? (check all that apply)
Low Blood Sugar
Ringing in the ears
Jaw Pain TMJ
Deep Vein Thrombosis
High Blood Pressure
Hepatitis A, B, or C
Any other issues not listed above?
Have you ever had problems with any of the following? (check all that apply)
If you selected any of the above problems, please explain in more detail:
How can we help you?
What is your chief complaint today?
What words would you use to describe your symptoms? Tingly, aching, throbbing, shooting, sharp, weak? Please be as detailed as possible.
How long have you had this condition?
How did this condition begin?
On a scale of 1 to 10, with 10 being the worst possible pain you can think of, how would you rate the pain you are in?
1 is Very Mild, 10 is Extreme Pain
What movements, postures or activities over the course of a day make your symptoms worse? Please be as detailed as possible
Is there anything that will make this condition better?
Has your condition been constant, or does it come and go?
Have you seen any other health care practitioner for this condition? If so, who and when?
If you referred to Performance Therapy, who referred you?
Should be Empty: