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Home
Meet the Staff
Videos
Therapy Services
Post Covid Recovery
Manual Therapy
Back & Neck Pain
Balance Training
Women's Pelvic Floor Rehab
Men's Pelvic Floor Therapy
Dry Needling
LSVT BIG (Parkinson's)
Lymphedema
Blood Flow Restriction
Sports Rehabilitation
Pre/Post Operative
Pediatric Therapy
Dizziness & Vertigo
Foot Pain
Functional Rehab For Chronic Conditions
Joint Pain
Other Services
Testimonials
Patient Center
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New Patient
Pre-Exam Form
In order to evaluate your conditon fully, please be as accurate as possible. Thank you
*
Indicates required field
Name
*
First
Last
Age
*
Gender
*
Male
Female
Occupation
*
Are you currently working?
*
Yes
No
Where is your pain/problem
*
What caused your pain/problem?
*
Approximately when did it start?
*
List ONE ACTIVITY you are unable to do, that you absolutely want to be able to do again:
*
In your understanding, what do you think will make it better?
*
What are you expecting from therapy?
*
List any Medications you are taking or bring a list to your 1st appointment: Please list the Name, Dosage, and Frequency
*
Do you have a Pacemaker?
*
Yes
No
Please list all prior surgeries/recent hospitalizations that may affect treatment-with dates:
*
list past surgeries and hospitalizations
Medical History (Check all that apply)
*
No Known Significant Prior Medical History to Affect Treatment
Alzheimer's
Cardiovascular Disease
Cauda Equina Syndrome
Saddle Anesthesia
Recent Onset Bladder Dysfunction
Cerebral Vascular Accident
Major Motor Weakness
.
*
Current Infection
Diabetes Mellitus Type 1
Diabetes Mellitus Type 2
Fibromyalgia
Fracture or Suspected Fracture
High Blood Pressure
History of Cancer
Huntington's
.
*
Immunosuppression
Lupus
Muscular Dystrophy
Obesity
Osteoarthritis
Parkinson's
Rheumatoid Arthritis
Traumatic Brain Injury
Comments on checked medical conditions/Other condition(s) not listed?
*
By typing my name and phone number below, I agree that all the questions were answered to the best of my ability. I understand that I will have a chance to review this form with my therapist once I begin therapy.
Please type name and phone number and press the
SUBMIT
button
. You will be directed to a page for Form #2.
Name
*
First
Last
Phone Number
*
Submit
Home
Meet the Staff
Videos
Therapy Services
Post Covid Recovery
Manual Therapy
Back & Neck Pain
Balance Training
Women's Pelvic Floor Rehab
Men's Pelvic Floor Therapy
Dry Needling
LSVT BIG (Parkinson's)
Lymphedema
Blood Flow Restriction
Sports Rehabilitation
Pre/Post Operative
Pediatric Therapy
Dizziness & Vertigo
Foot Pain
Functional Rehab For Chronic Conditions
Joint Pain
Other Services
Testimonials
Patient Center
Contact
Insurance/Billing
FAQ
Direct Access
Career