Have you had Surgery for this Injury? *

YES

NO

Have you had any of the following diagnostic, medical or rehabilitative services for this injury/episode? Check all that apply: *

Chiropractor

Massage Therapy

Occupational Therapy

Physical Therapy

Emergency Room

Neurologist

Orthopedist

Podiatrist

Have you ever had any of the follow? Check all that apply: *

CT Scan

MRI

EMG

X-Rays

Myelogram

Do you or have you had any of the follow? Check all that apply: *

Heart Attack or Heart Surgery

Coronary Heart Disease or Angina

High Blood Pressure

Shortness of Breath/Chest Pain

Dizziness or Fainting

Stroke/TIA

Blood Clot/Emboli

Severe or Frequent Headaches

Asthma, Bronchitis, or Emphysema

Infectious Diseases

Diabetes

Cancer/Chemotherapy/Radiation

Thyroid Trouble/Goiter

Bowel or Bladder Problems

Epilepsy/Seizures

Osteoporosis

Gout

Vision or Hearing Difficulties

Numbness or Tingling

Neck Injury/Surgery

Shoulder/Elbow/Hand Injury

Back Injury/Surgery

Hip/Knee Injury/Surgery

Leg/Ankle/Foot Injury/Surgery

Arthritis/Swollen Joints

Hernia

Varicose Veins

Joint Replacement

Weight Loss/Energy Loss

Sleeping Problems/Difficulties

Emotional/Psychological Problems

Weakness

Allergies

Do you smoke? *

YES

NO

Do you have any pins or metal implants? *

YES

NO

Do you have a pacemaker? *

YES

NO

Are you pregnant? *

YES

NO

Date *

MM

DD

YYYY