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
 stroke heart attack high blood pressure COPD/asthma Blood clots coronary artery disease peripheral vascular disease/circulation problems diabetes kidney disease or stones Hepatitis Thyroid disease Cancer Coagulation disorder Gastritis/ulcers/reflux Psychiatric treatments HIV/AIDS Left hand dominant Right hand dominant VARICES OTHER

If other please specify

Family History
 Diabetes High blood pressure Heart disease Stroke Cancer Lupus Rheumatoid arthritis Fibromyalgia Varices

At the present time are you experiencing:
 Fever Weight Loss Weght Gain Sleepiness Blurry Vision Double Vision Blind Spots Trouble Chewing Choking Dry Mouth Palpitation Chest Pain Fainting Wheezing Coughing Shortness Of Breath Heartburn Nausea Vomiting Constipation Diarrhea Incontinence Pain Urination Blood In Urine Numbness Tingling Balance Difficulties Spasms Burning Global Weakness Or Myalgia Joint Pain Swelling Neck Pain Back Pain Anxiety Depression Suicidal Thoughts Or Attempts Insomnia Memory Issues Excessive Thirst Hair Loss Sexual Problems Skin Rashes Eczema

Briefly describe responses to your past treatments

Past tests and please attach the reports and or photos
 Lab XRAY MRI EMG Other

Past treatments?
 Physical therapy Osteopathy Massage Epidural injection Surgery Dental procedures Dry needles therapy Acupuncture Dry cupping therapy

Pain

When did your symptoms begin?Briefly describe

cause
 Work injury Car accident Spontanious onset sports injury Other

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:
 Constant Sharp Stabling Burning Throbbing Intermittent Dull Shooting Aching Other

If other please specify

Do you experience:
 Numbness Tingling Weakness Other

If other please specify

What increases your pain?
 Walking Lifting Lying Twisting sitting walking heat activity Bending standing reaching

What decreases your pain?
 heat Ice Rest Reclining Sitting walking Activity Standing Other

If other please specify

Does pain interfere with?
 work daily activities social life hobbies relationships

Where would you rate your pain?
 0 (NO PAIN) 1 2 3 4 5 6 7 8 9 10 (WORST IMAGINABLE PAIN)

Feel free to contact us on

+961 3 672 551

info@drelieatallah.com