Name:

Referring Physician:

Family Physician:

Date of First Doctor Visit for this Illness:

Last Date Worked Due to Illness:

Date Returned to Work After This Illness:

Is an Attorney involved in this Case:              YES       NO

Have you had Surgery for this illness?            YES       NO

Number of Surgeries:    1    2    3    4

Type of Surgery:

Took Place In:     Hospital   /   Surgery Center

Are you currently Taking Any Prescription or Non-Prescription Medication?     YES     NO

Anti-Viral

List Medications

Diuretic

Pain Medication

Have you had any of the following Medical or Rehabilitative Services for this Illness/Episode?

YES

NO

YES

NO

ENT/Neurologist

CT Scan

General Practitioner

ENG

Chiropractor

MRI

Physical Therapy

X-Rays

Massage Therapy

Emergency Room Care

Other:

Do you now have or Have you ever had ANY of the following?

YES

NO

YES

NO

Asthma, Bronchitis, or Emphysema

Severe or Frequent Headaches

Shortness of Breath/Chest Pain

Vision or Hearing Difficulties

Coronary Hearst Disease or Angina

Numbness or Tingling

Do you have a Pacemaker?

Dizziness or Fainting

High Blood Pressure

Ringing in ears

Heart Attack or Surgery

Weakness

Stroke/TIA

Weight Loss/Energy Loss

Blood Clot/Emboli

Hernia

Epilepsy/Seizures

Vericose Veins

Thyroid Trouble/Goiter

Allergies

Anemia

Any Pins or Metal Implants

Infectious Diseases

Joint Replacement

Diabetes

Neck Injury/Surgery

Cancer or Chemotherapy/Radiation

Shoulder Injury/Surgery

Arthritis/Swollen Joints

Elbow/Hand Injury/Surgery

Osteoporosis

Back Injury/Surgery

Gout

Knee Injury/Surgery

Sleeping Problems/Difficulties

Leg/Ankle//Foot Injury/Surgery

Emotional/Psychological Problems

Are You Pregnant?

Bowel or bladder Problems

Do You Smoke?

List any other information that would assist us in your care:

Are you aware of what your diagnosis is?       YES       NO

Based upon your awareness, what are your expectations/goals while in this program?

Patient/Guardian Signature:

Date: