* required entries
 Name: *
 Age: *
 Gender: *
 Email: *
 Phone: *
 Date: *
 
 Describe the exact location of your problem:
    Neck Upper Back Lower Back Arm Leg

 Describe the origin of your injury:
    Lifting Twisting Fall Bending Pulling

 List and rate the symptoms you are experiencing in order of severity
  (on a 1 – 10 scale with 1 being no pain and 10 being unbearable)
 Ache   Burning   Numbness
 Sharp/stabbing   Tingling

List the doctors that you have been to with this problem (please note referring doctor:


 Do you want us to send the referring doctor a report? Yes No

 List any major illness or medical problems you have had:


 List all surgeries that have been performed on you:


 List all allergies to medication you have:


 List all medications you are currently taking:


 Have you taken Cortisone? Yes No
 How much?   How long?
 What disease was being treated?