Consultation Request Form
Name
First Name
*
Address
*
City
*
State
*
Zip Code
*
Last Name
*
Date of Birth
*
Height
*
Weight
*
How did you hear about us?
Mobile Number
*
Email Address
*
Marital Status
*
Married
Single
Widowed
Spouse's Name
Spouse's Phone Number
Employed?
*
Yes
No
# of Years Employed
Name of Employer
General Symptoms (check all that apply)
Foot Pain
Hand Pain
Low Back Pain
Neck Pain
Foot Numbness
Hand Numbness
Diabetes
High Cholesterol
High Blood Pressure
Pacemaker/Defibrillator
Herniated Disk
Bulging Disk
Spinal Stenosis
Degenerative Disc
Spinal Stenosis
Vascular Problems
Leg Pain
Plantar Fasciitis
Morton's Neuroma
Cancer
Chemotherapy
Arthritis in Hand
Arthritis in Feet
Implanted Cord/Bladder Stimulator
Sciatica
Pinched Nerve
Poor Circulation
Joint Replacement
Foot Surgery
Poor Wound Healing
Excessive Thirst or Urination
Hip Pain
Knee Pain
Organ Transplant
Dental History (check all that apply)
Loose Teeth
Root Canals
Crooked Teeth
Gum Recession
Ailing Implants
TMJ
Chronic Bad Breath
Amalgams - Silver/Mercury
Extractions
Missing Teeth
Present Health Condition
Please list the issues you are interested in correcting in the order of importance
Approximately how long have you noticed these symptoms?
Name of Primary Care Provider
When were you last seen?
Phone Number of Primary Care Provider
May we send them updates?
Yes
No
List any previous surgeries with the date they occurred
List all allergies or sensitivities to food, medication, etc.
How do you react to those allergies?
List any prescription drugs you are taking along with dosage and frequency.
List all nutritional supplements (vitamins, herbs, homeopathies, etc.) along with dosage and frequency.
Please select the type of pain you are experiencing listed below (if any)
Numbness
Tingling
Soreness
Pain
Ache
Stiffness
Is there a time of day the symptoms are better or worse?
Check all of the things you have used for these problems.
Aleve
Tylenol
Ibuprofen
Motrin
Aspirin
Massage Therapy
Physical Therapy
Where are you experiencing the pain?
Neck
Back
Knees
Elbows
Feet
Head
Hips
Is your balance/walking ability affected? Please describe.
What do you think causes your problem?
Please list the doctors you have seen for these problems and the treatments you have received.
Since seeing the doctors, have your symptoms
Improved
Worsened
Stayed the Same
List anything that makes your condition worse.
List anything that makes your condition better.
How would you describe the symptoms? Please check all that apply.
Aching Pain
Stabbing Pain
Sharp Pain
Fatigue
Numbness
Tingling
Pins & Needles Pain
Heavy Feeling
Hot Sensation
Throbbing Pain
Dead Feeling
Cold Hands / Feet
Cramping
Swelling
Electric Shocks
Reduced Mobility
Is your condition interfering with any of the following?
Sleep
Recreational Activities
Work
Walking
Daily Activities
Standing
Do you smoke?
Yes
No
Do you exercise daily?
Yes
No
Do you drink?
Yes
No
On a scale of 1-10, with 1 being no pain and 10 being the worst pain possible, how would you rate your pain in the last week?
On a scale of 1-10, with 1 being no pain and 10 being the worst pain possible, if you had to accept some level of pain after completion of treatment, what would be an acceptable level?
