ALL INFORMATION IS KEPT STRICTLY CONFIDENTIAL

SECTION #1

Present Field - Do Not Change: CONTRAINDICATIONS FOR ARP --------------------

Your Full Legal Name:

Please check all present symptoms related to your current condition:
 

Are you pregnant: PLEASE SELECT... Yes, pregnant No, not pregnant     (If YES, not qualified)
 

Any pacemaker or ICD: PLEASE SELECT... Yes, I have a Pacemaker or ICD No Pacemaker or ICD (If YES, not qualified)
 

Do you have a Blood clot or any history of blood clots: PLEASE SELECT... Yes, Blood Clot history No Blood Clot history (If YES, not qualified)

NOTE: If you answered YES to any of the above questions we can not help you.
 

Where Is The Location Of Your Pain:

Rate The Intensity Of Your Pain When Doing A Movement That Bothers You: PLEASE SELECT... 0-1 No Pain 2-3 Mild Pain 4-5 Moderate Pain 6-7 Severe Pain 8-9 Very Severe Pain 9-10 Worst Possible Pain

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Present Field - Do Not Change: CURRENT CONDITION --------------------

When did your complaint/symptoms begin:

Describe your complaint/symptoms:   

Where is the location of your pain:      

What does your pain feel like:                PLEASE SELECT... Aching Burning Numbness Pins & Needles Stabbing

What was the cause of the symptoms: PLEASE SELECT... Auto Accident Athletic Injury Work Related Injury Post Surgery Just Came on

What activity bothers you the most:    

What activity lessens your symptoms:

How have symptoms progressed:        

What treatments have you done (check all that apply):

Massage    Medication    Physical Therapy    Rest / Ice / Compression
Surgery     Chiropractic   Alternative     Laser   Acupuncture;

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Preset Field - Do Not Change: MEDICAL HISTORY --------------------

Have you seen a doctor because of your current condition: PLEASE SELECT... Yes No   

If so, what was the result:

Do you have any allergies, if so list them:   

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Preset Field - Do Not Change: DIAGNOSTIC TESTS --------------------

Have you had any diagnostic tests performed by any Doctors (check all that apply):

MRI    X-Rays    Lab Work    Functional Testing   Psychological Testing    Electro diagnostics    Others

If so, what were the results of the test :

Are there any additional comments about your condition that you feel would be important for us to know:

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SECTION #2

Year of Birth: Today's Date:

Home Address :  City :    Prov :   

Zip :

Home Phone : Work Phone : Cell Phone :  

Best Time To Call To Setup An Appointment With You: Best Number To Call: PLEASE SELECT... Home # Work # Cell #

Sex: PLEASE SELECT... Male Female

E-mail:

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