Patient Record

Fill in the Form or call us directly at +961 3 672 551

Personal Information

First Name (required)

Your Email (required)

Address(required)

Blood Type

Job and education

Referred By?

Insurance name

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

weight/Height

Sports / Activities

Family physician?

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?

Medical History

Allergies(Medication,food/other)

Vaccinations

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

Family History
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
LabXRAYMRIEMGOther

Past treatments?
Physical therapyOsteopathyMassageEpidural injectionSurgeryDental proceduresDry needles therapyAcupunctureDry cupping therapy

Pain

When did your symptoms begin?Briefly describe

cause
Work injuryCar accidentSpontanious onsetsports injuryOther

If other please specify

Ever had such symptoms in the past?Explain

Since the onset of the problem has your symptoms changed?if yes how?

Are your symptoms:
ConstantSharpStablingBurningThrobbingIntermittentDullShootingAchingOther

If other please specify

Do you experience:
NumbnessTinglingWeaknessOther

If other please specify

What increases your pain?
WalkingLiftingLyingTwistingsittingwalkingheatactivityBendingstandingreaching

What decreases your pain?
heatIceRestRecliningSittingwalkingActivityStandingOther

If other please specify

Does pain interfere with?
workdaily activitiessocial lifehobbies relationships

Where would you rate your pain?
0 (NO PAIN)12345678910 (WORST IMAGINABLE PAIN)

Feel free to contact us on

+961 3 672 551

info@drelieatallah.com