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First Name (required)
Your Email (required)
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
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
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
Physical therapy Osteopathy Massage Epidural injection Surgery Dental procedures Dry needles therapy Acupuncture Dry cupping therapy
When did your symptoms begin?Briefly describe
Work injury Car accident Spontanious onset sports injury Other
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
Do you experience:
Numbness Tingling Weakness Other
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
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)
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+961 3 672 551