NEURO TTHERAPY NETWORK PATIENT INTAKE FORM
 
Date (dd-mm-yyyy):
Therapist Name
Clinic Name
Doctor Name
Patient Name:
Email Address:
Home Street Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Cell:
Sex:
Male Female
Date of Birth (dd-mm-yyyy):
Marital Status:
Married Single Divorced Widowed
Student Status:
Employment Status:
Full Time
Part Time
Unemployed
Retired
Emergency Contact:
Phone:
CONTRAINDICATIONS FOR ARP - Please check all present symptoms related to your current condition:
Are you pregnant:
Yes No
Any Pacemaker:
Yes No
Any history of blood clots:
Yes No
To help meet your needs, please indicated your specific interests:
Rate the intensity of your pain:
1 No Pain
2
3
4
5
6
7
8
9
10 Worst Possible Pain
Describe your complaint\symptoms:
When did your complaint\symptoms begin:
What was the cause of the symptoms:
What does your pain feel like:
Aching
Burning
Numbness
Pins & Needles
Stabbing
Tightness
How have the symptoms progressed:
What movement or activity bothers you most:
Have you had surgery:
Yes No
Have you been told you need surgery:
Yes No
What have you done to relieve symptoms?
Are you taking any medication for your symptoms:
What other treatments have you done (check all that apply):
Massage
Medication
Physical Therapy
Rest/Ice/Compression
Surgery
Chriropractic
Acupuncture
Other
Have you seen another doctor because of your current condition:
Yes No
Doctors name:
Phone:
Result of visit:
Truthful Representation:
Upon selecting the following box stating "ALL INFORMATION IS TRUE" I hereby state that all the information I have provided is true, correct and complete. If more information about my condition becomes known, I will tell the doctor when possible so that it can be added to my record
All information is true:
Initials:
Release of Liability:
In conjunction with my Neuro Therpay treatment and as part of the consideration for my treatment, I, my heirs, executors, spouse, successors, assigns, offspring, agents, and representatives expressly release, hold harmless, and indemnify ARP Wave LLC, its owners, agents, employees, representatives, assignees, licensees, and invitees, from all liability for any treatments given.
After you have answered all the questions, sign below:
Type your signature below

 
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