Initial Patient Visit Form

First and Last Name

Medication Details


Medication allergies


Surgeries and Hospitalizations


Select area where you have pain

Right Shoulder Left Shoulder Left Shoulder Lower Back
Rotate Left Rotate Right
Left Shoulder
Right Shoulder
Left Hand
Right Hand
Hip
Knee
Left Foot
Right Foot

Pain Details

Please descibe your pain
Please describe the reason of the pain
Other items that INCREASE your pain
Other items that DECREASE your pain
Other items that INCREASE your pain

PREVIOUS PAIN TREATMENT / THERAPY ( check all that apply) :


CURRENT AND PREVIOUS PAIN MEDICATIONS AND RESULTS:


DO YOU USE ANY OF THE FOLLOWING DEVICES:

TESTS AND RADIOLOGICAL STUDIES: