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: ____________________
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- american financial relief center reviews
- best joint pain relief supplement
- best joint pain relief products
- american financial relief center scam
- pain relief for tmj
- nerve pain relief cream
- nerve pain relief leg
- topical pain relief for neuropathy
- arthritis pain relief for knees
- pain relief injection
- national relief center scam
- lower back pain relief massager