Lasting Pain Relief Center – Ready to feel great?



LASTING PAIN RELIEF CENTER

CLIENT HISTORY Date ____________

Name _______________________________ Email: ____________________

Address _____________________________ City/State _____________ Zip _______

Phone _______________________________ Occupation ______________________

Age _____ Height _____ Weight _______

Date of Birth _______________ How did you hear about us? _____________

Referring Physician or Therapist ________________________

Address _________________________ Phone ___________

The form is very important in your evaluation process. Please fill it out as specifically as possible to provide us with a clear picture of your present pain and functional status.

1. What is the primary complaint that brings you to here today?

Secondary complaint?

As a result, I am now having difficulty with:

Are you currently experiencing pain as a result of these symptoms?

Do you have any scars? If so, where? ___________________________________________________________

2. When and how did your symptom(s) begin? Date: __________________________________________

3. Have you ever received the following treatment for this condition?

Yes No How long? Helpful?

Physical Therapy ___ ___ _____________ _________________

MFR ___ ___ _____________ _________________

Chiropractic ___ ___ _____________ _________________

Other ___ ___ _____________ _________________

4. Check the box if you have had any of the following medical conditions?

____ Diabetes ____ Varicose veins ____ Neurological problems ____Heart disease/pacemaker

____ Stroke ____ Heart Murmur ____ Rheumatic fever ____ Circulatory problems

____ Arthritis ____ Lung disease ____ Broken bones (fracture) ____ High blood pressure

____ Pregnancy ____ Kidney disease ____ Epilepsy/seizures ____ Migraine headaches

____ Malignancy ____ Liver disease ____ Metal implants ____ Weight change

____ Blackouts ____ Osteoporosis

____ Other: explain ________________________________________________________________

5. List past medical history and dates of occurrence. Include surgeries, accidents and other traumas.

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

6. List ALL medications which you are currently taking, the problem for which you are using them, the dose, and their effectiveness. (Include supplements,herbal and homeopathic remedies).

Medication For treatment of Dose/Amt. per day Effectiveness

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

7. Do you have any skin or medication allergies? Yes No

If so, which? _______________________________________________________________

8. Is there a chance you may be pregnant at this time? Yes No

9. Do you smoke? Yes No cigar/cigarettes/pipe How much? ____________________

When did you quit? ______________________

10. Please place an “M” in front of each item that you experience at least MONTHLY. Place a “W” in front of each item that you experience WEEKLY or more frequently.

___ Headaches ___ Chest pain, tightness

___ Feeling inadequate/unable to cope ___ Sweaty palms

___ Feeling guilty or like a failure ___ Easily annoyed or irritated

___ Coughing ___ Excessive perspiration

___ Numbness, tingling in arms or legs ___ Eyestrain or discomfort

___ Nosebleeds ___ Uncontrolled crying or sadness

___ Stomach cramps ___ Free-floating anxiety about life

___ Can’t keep warm enough ___ Blushing/flushed face

___ Stuffy nose, congestion ___ Eyes irritated or inflamed

___ Visual disturbances – blurry ___ Earache or ringing noise in ears

___ Common colds ___ Heartburn/indigestion

___ Sore throat ___ Nausea or vomiting

___ Asthma or shortness of breath ___ Frequent urination

___ Hay fever or allergies ___ Incomplete urination

___ Sore, aching muscles ___ Painful urination

___ Stiff or tender joints ___ Urinary leakage

___ Back problems ___ Bowel leakage

___Trembling/twitching muscles ___ Diarrhea

___ Skin rashes, eruptions ___ Constipation

___ Grinding of teeth (TMJ) ___ Bowel irregularity

___ Dry mouth ___ Frequent laxative use

___ Mouth sores ___ Uninterested in sex relations

___ Difficulty falling asleep ___ Unable to enjoy sexual activity

___ Difficulty sleeping through night ___ Menstrual difficulties

___ Awaken too early in morning ___ Pre-menstrual syndrome (PMS)

___ Excessive drowsiness during day ___ Breast tenderness

___ Periods of extreme fatigue ___ Hot flashes

___ Feeling faint or dizzy ___ Water retention

___ Feeling tense or nervous ___ Over-eating, bingeing

___ Difficulties with family or friends ___ Lack of appetite

___ Worrisome thoughts ___ Excessive alcohol abuse

___ Recurring bad thoughts ___ Other substance abuse

___ Thoughts of suicide ___ Fearful of persons or places

___ Other: ______________________________

11. Please rate the intensity of your pain with “0” being no pain, “5” being moderate pain, and “10” being unbearable pain. Your Pain Intensity Rating: _______

12. Please rate the frequency of your pain with “0” being never, “5” being intermittent, and “10” being constant. Your Pain Frequency Rating: ______

13. More specifically, rate your pain using the same “0” to “10” scale.

At its worst _____ At its best _____ Most of the time ____ Night (sleeping) ____

14. At what time of day are your symptoms the worst? ___________________

At what time of day are your symptoms the best? ___________________

15. Do you engage in regular exercise? Yes / No

What type and how often? ___________________________________________________

Are you able to exercise now? Yes / No

Do you have discomfort, shortness of breath, or pain with exercise?

16. In general, your lifestyle is: 1 2 3 4 5

Active Average Inactive

17. If sleep is a problem, answer these questions:

Do you have trouble falling asleep? Yes / No Is your sleep restful? Yes / No

Do you find it difficult to lie down? Yes / No

To come to a sitting position from lying down? Yes / No

Do you find it difficult to change positions in bed? Yes / No

How many times do you wake in the night? _____

How long before you fall back to sleep? _______

18. What activities increase your pain? ___________________________________________

What activities decrease your pain? __________________________________________

19. Daily Activities. Please estimate the amount of time, on average, you spend in

each of the following activities per day.

Sleeping ____ Working ____ Household Chores ____

Sitting at desk ____ Talking on phone ____ Driving ____ Standing in place ____ Computer Work ____ Playing (specify sports & hobbies) ____

Other ___________________________

How much total time do you tolerate being in a vertical position per day? (e.g.

sitting, standing, walking, driving) _____ hour(s)

If you need to rest during the day, how often? _____And what is the total time? ____ hours

How much total time do you tolerate being in a horizontal position per day? (e.g.

reclining, laying down, sleeping) ____ hour(s)

I walk for ____minutes before needing to rest.

I stand for ____minutes before needing to sit.

I sit for ____minutes before needing to change positions/get up.

Do you have trouble getting up from a chair? Yes / No

Do you have trouble putting on your shoes and socks? Yes/ No

Do you have difficulty climbing stairs? Yes / No

20. If any daily activities are limited, answer this question.

List all the Tasks/Activities that you have difficulty performing and your tolerance (minutes/hours) for each task/activity. If you are no longer able to perform an activity, your tolerance would be “0”.

Task/Activity Tolerance

1. _______________________________________ 1. _____________________________

2. _______________________________________ 2. _____________________________

3. _______________________________________ 3. _____________________________

4. _______________________________________ 4. _____________________________

5. _______________________________________ 5. _____________________________

21. Functional Ability. On the line scale below, place a check mark to indicate your level of daily functional ability.

Inactive Normal

On a good day 0% __________________100%

On a bad day 0%__________________ 100%

22. Patient Goals. List the activities that you would like to be able to do as a result of therapy.

Activity Duration/How Often By When

1. ______________________ _______________________ ___________________

2. ______________________ _______________________ ___________________

3. ______________________ _______________________ ___________________

4. ______________________ _______________________ ___________________

Other Goals? ________________________________________________________

LASTING PAIN RELIEF CENTER

Massage, bodywork and somatic therapy practices are designed to promote and maintain the health and well-being of the client and do not include the diagnosis or treatment of illness, disease, impairment or disability. If I experience pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. Because massage, bodywork and somatic therapy may be contraindicated due to certain medical conditions, I affirm that I have informed the therapist of all my known medical conditions and will keep the therapist updated as to any changes in my medical condition.

To the best of my knowledge, the information I have provided is accurate and true. I understand that I am an active participant in my healing and it is my responsibility to provide accurate and timely feedback to my therapist regarding my response to treatment. I understand that I am in full control of my treatment and have the right to halt any technique at any time by asking my therapist to ease up or stop completely, which will be complied with immediately. I am aware that ‘tissue memory’ may occur during and after treatment and that I am free to express emotions (crying, laughter, sounds, anger, movement, etc.) as my body needs, while my therapist keeps me safe during these normal responses. I am also aware that pain symptoms may increase during and after treatment as part of the healing process.

I have read, understood, and agreed to the conditions of the HIPAA Notice of Privacy Practices. By signing below, I acknowledge I have read and understand the above, and consent to treatment.

CANCELLATION POLICY is 24-hours Advanced Notice in CA and NJ, and 48 hours in NY. Since your appointment time is set aside specifically for you, we require that all clients extend a courteous 24 or 48 hour cancellation notice to change or cancel any appointment. If less than 24 or 48 hour notice is given, the full session fee is due immediately. All Intensive Treatments are reserved and paid for in advance and are nonrefundable. If a cancellation is made to an Intensive schedule, the remaining hours may be used in future visits within the next 12 months.

Client Signature: X__________________________________________ Today’s Date: ____________________

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