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First Name (required)
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Job and education
Insurance expiry date
Chief Complaint:(What is the reason for your visit?)
How much water or any fluid do you drink per day?
Family Name (required)
Your Phone Number
Date of birth
Sports / Activities
Family status and number of children if there is any
Do you: Smoke,drink alcohol,drink coffee or tea?and how much per day or per week
How many hours do you sleep?
List of medications including vitamins and minerals and current dosage
List of medication taken in the past caused side effects or did not relieve pain
Medical History: Please check all that apply
strokeheart attackhigh blood pressureCOPD/asthmaBlood clotscoronary artery diseaseperipheral vascular disease/circulation problemsdiabeteskidney disease or stonesHepatitisThyroid diseaseCancerCoagulation disorderGastritis/ulcers/refluxPsychiatric treatmentsHIV/AIDSLeft hand dominantRight hand dominantVARICESOTHER
If other please specify
DiabetesHigh blood pressureHeart diseaseStrokeCancerLupusRheumatoid arthritisFibromyalgiaVarices
At the present time are you experiencing:
FeverWeight LossWeght GainSleepinessBlurry VisionDouble VisionBlind SpotsTrouble ChewingChokingDry MouthPalpitationChest PainFaintingWheezingCoughingShortness Of BreathHeartburnNauseaVomitingConstipationDiarrheaIncontinencePain UrinationBlood In UrineNumbnessTinglingBalance DifficultiesSpasmsBurningGlobal Weakness Or MyalgiaJoint PainSwellingNeck PainBack PainAnxietyDepressionSuicidal Thoughts Or AttemptsInsomniaMemory IssuesExcessive ThirstHair LossSexual ProblemsSkin RashesEczema
Briefly describe responses to your past treatments
Past tests and please attach the reports and or photos
Physical therapyOsteopathyMassageEpidural injectionSurgeryDental proceduresDry needles therapyAcupunctureDry cupping therapy
When did your symptoms begin?Briefly describe
Work injuryCar accidentSpontanious onsetsports injuryOther
Ever had such symptoms in the past?Explain
Since the onset of the problem has your symptoms changed?if yes how?
Are your symptoms:
Do you experience:
What increases your pain?
What decreases your pain?
Does pain interfere with?
workdaily activitiessocial lifehobbies relationships
Where would you rate your pain?
0 (NO PAIN)12345678910 (WORST IMAGINABLE PAIN)
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+961 3 672 551