Privacy & Consent Step 1 of 3 33% Patient InformationName* First Last Date* MM slash DD slash YYYY AgeDate of Birth* MM slash DD slash YYYY Gender Male Female Height Weight Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Cell PhoneHome PhoneWork PhoneEmail* Emergency Contact Name First Last Emergency Contact PhoneRelation to Patient Will you be submitting a bill to your insurance? Yes No Have Medicare / Medicaid Patient HistoryDescribe the current problem that brought you here?When did your problem first begin? Was your first episode of the problem related to a specific incident? Yes No Please describe and specify date:Since that time is it: Staying the same Getting worse Getting better Why or howIf pain is present rate pain on a 0 – 10 scale 10 being the worst.Please enter a number from 0 to 10.Describe the nature of the pain (i.e. constant burning, intermittent ache)Describe previous treatment/exercise.Activities/events that cause or aggravate your symptoms. Sitting for periods of time Walking for periods of time Standing for periods of time Changing positions (i.e. – sit to stand) Light Activity (Light Housework) Vigorous Activity/Exercise Sexual Activity With Cough With Sneeze With Straining With Laughing With Yelling With Lifting With Bending With Cold Weather With Triggers: Running Water With Triggers: Key In Door With Nervousness With Anxiety No activity affects the problem Other, please list Sitting longer than (in minutes)*Walking longer than (in minutes)*Standing longer than (in minutes)*Other, please list* What relieves your symptoms?How has your lifestyle/quality of life been altered/changed because of this problem?Rate the severity of this problem from 0 – 10 with 0 being no problem and 10 being the worstPlease enter a number from 0 to 10.What are your treatment goals/concerns?List other areas of painSince the onset of your current symptoms have you had: (Check all that apply) Fever/Chills Unexplained Weight Change Dizziness or Fainting Change in Bowel or Bladder Functions Malaise Unexplained Muscle Weakness Night Pain / Sweats Numbness / Tingling Other, please describe Other, please describe: Health HistoryDate of Last Physical Exam MM slash DD slash YYYY Tests PerformedGeneral Health Excellent Good Average Fair Poor Occupation Hours per Week? Disability or Leave? Activity Restrictions? Current Level of Stress High Med Low Current psych therapy? Yes No Activity/Exercise None 1-2 days/week 3-4 days/week 5+ days/week DescribeHave you ever had any of the following conditions or diagnoses? (Check all that apply) Cancer Heart Problems High Blood Pressure Ankle Swelling Anemia Low Back Pain Sacroiliac/Tailbone Pain Alcoholism/Drug Problem Childhood Bladder Problems Depression Anorexia/Bulimia Smoking History Vision/Eye Problems Hearing Loss/Problems Stroke Epilepsy/Seizures Multiple Sclerosis Head Injury Osteoporosis Chronic Fatigue Syndrome Fibromyalgia Arthritic Conditions Stress Fractures Rheumatoid Arthritis Joint Replacement Bone Fracture Sport Injury TMJ/Neck Pain Emphysema/Chronic Bronchitis Asthma Allergies (list below) Hypothyroid/Hyperthyroid Headaches Diabetes Kidney Disease Irritable Bowel Syndrome Hepatitis HIV/Aids Sexually Transmitted Disease Physical or Sexual Abuse Raynaud's (Cold Hands and Feet) Pelvic Pain Other, Please describe Please list your AllergiesOther, please describeSurgical / Procedure History Surgery for your Back/Spine Surgery for your Brain Surgery for your Female Organs Surgery for your Bladder/Prostate Surgery for your Bones/Joints Surgery for your Abdominal Organs Other, please describe Other, please describeTraumas/Falls/FracturesOb/Gyn History (females only) Childbirth Vaginal Deliveries Episiotomy C-Section Difficult Childbirth Prolapse or Organ Falling Out IUD Vaginal Dryness Painful Periods Menopause Painful Vaginal Penetration Pelvic Pain DC/Abortion Miscarriage Fibroids Ovarian Cysts Endometriosis Other, please describe Number of Childbirth Vaginal DeliveriesNumber of EpisiotomiesNumber of C-SectionsNumber of Difficult ChildbirthsDate of Menopause MM slash DD slash YYYY Other, please describeDate of last menses MM slash DD slash YYYY Males Only Prostate Disorders Shy Bladder Pelvic Pain Erectile Dysfunction Painful Ejaculation Other, please describe Other, please describePlease list any medications - pills, injections, patch - the start date and reason for takingPlease list any over the counter - vitamins, etc. - the start date and reason for taking Δ