Full Name:
Today's Date
Birthday
Age:
Social Security Number:
Address:
City:
State:
ZIP:
Cell Phone Number:
Email:
Occupation:
Spouse first name:
Spouse phone #:
Do you currently have active cancer and/or you currently treating cancer?
Yes
No
Are you expecting insurance to pay for this?
Yes
No
What Problem Are You The Most Frustrated About That We Can Help You With?
Other problems that you would like our help with?
What have you done to treat the above problems?
How is that treatment system working?
Are you worried that your problem is getting worse?
Yes
No
Are you angry that nobody has been able to get your problem fixed?
Yes
No
Have your symptoms?
Improved Worsened
Stayed the same
What makes your condition Worse?
What makes your condition Better?
List the doctors that you have seen for these problems, treatment you received:
How would you rate your pain in the last week?
NO PAIN
1
2
3
4
5
6
7
8
9
10
WORST PAIN POSSIBLE!
If you had to accept some level of pain after completion of treatment, what would be an acceptable level?
NO PAIN
1
2
3
4
5
6
7
8
9
10
WORST PAIN POSSIBLE!
Headache
Yes/No.
How often & long?.
Where?.
Dr. Notes.
Neck Pain
Yes/No.
How often & long?.
Where?.
Dr. Notes.
Mid Back Pain
Yes/No.
How often & long?.
Where?.
Dr. Notes.
Low Back Pain
Yes/No.
How often & long?.
Where?.
Dr. Notes.
Difficulty Sleeping
Yes/No.
How often & long?.
Where?.
Dr. Notes.
Stiffness
Yes/No.
How often & long?.
Where?.
Dr. Notes.
Numbness/Tingling
Yes/No.
How often & long?.
Where?.
Dr. Notes.
Shoulder Pain
Yes/No.
How often & long?.
Where?.
Dr. Notes.
Degeneration
Yes/No.
How often & long?.
Where?.
Dr. Notes.
Fatigue
Yes/No.
How often & long?.
Where?.
Dr. Notes.
Arm/Hand problems
Yes/No.
How often & long?.
Where?.
Dr. Notes.
Hip problems
Yes/No.
How often & long?.
Where?.
Dr. Notes.
Leg problems
Yes/No.
How often & long?.
Where?.
Dr. Notes.
Knee problems
Yes/No.
How often & long?.
Where?.
Dr. Notes.
Foot problems
Yes/No.
How often & long?.
Where?.
Dr. Notes.
Heart/circulation issues
Yes/No.
How often & long?.
Where?.
Dr. Notes.
Stomach/Reflux
Yes/No.
How often & long?.
Where?.
Dr. Notes.
Lungs
Yes/No.
How often & long?.
Where?.
Dr. Notes.
Nerves/ M.S.
Yes/No.
How often & long?.
Where?.
Dr. Notes.
Diabetes
Yes/No.
How often & long?.
Where?.
Dr. Notes.
Cancer
Yes/No.
How often & long?.
Where?.
Dr. Notes.
Rheumatoid Arthritis
Yes/No.
How often & long?.
Where?.
Dr. Notes.
Peripheral Neuropathy
Yes/No.
How often & long?.
Where?.
Dr. Notes.
Infections
Yes/No.
How often & long?.
Where?.
Dr. Notes.
Blood Pressure
Yes/No.
How often & long?.
Where?.
Dr. Notes.
Colon (const/diarrhea)
Yes/No.
How often & long?.
Where?.
Dr. Notes.
Kidney/Bladder
Yes/No.
How often & long?.
Where?.
Dr. Notes.
Reproductive organs
Yes/No.
How often & long?.
Where?.
Dr. Notes.
Are you allergic to sulfa?
Yes
No
Other Allergies?
Surgeries that you have had:
Accidents/Broken Bones:
Smoke?
Yes
No
How Much/Often?
Drink?
Yes
No
How Much/Often?
Exercise?
Exercise?
Yes
No
How Much/Often?
List the prescription drugs you are currently taking (or you may attach a list):
Name.
Condition Treating.
Dose and Frequency.
List all nutritional supplements (vitamins, herbs, homeopathies, etc.):
Name.
Reason for Taking.
Dose and Frequency.
Signature
Clear