Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Primary Reason for Contacting Us *

Choose all that apply

Hormone Replacement Therapy

Pain Management

Pain Injections

Vitamin B Injections

Vitamin D Injections

Nutritional Consulting Services

Functional Medicine

Weight Loss

Peptides (For surgery free healing or performance)

Nutritional Testing

IV Therapy

Platelet Rich Plasma (PRP)

Human Performance Optimization

Other

Mobile Phone *

(###)

###

####

How may we contact you? *

Cell Phone

Text

E-Mail

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact

First Name

Last Name

Emergency Contact Phone Number

(###)

###

####

Primary Care Physician

First Name

Last Name

Primary Care Physician Phone

(###)

###

####

Family History *

Have any of your parents, grandparents, or siblings experienced any of the following?

None

Heart Disease

Diabetes

Cancer

Severe Depression

Alzheimer's or Dementia

Other

Personal Medical History *

High blood pressure

Heart bypass

High cholesterol

Heart Disease (other)

Heart attack

Angina or other chest pain

Stroke or TIA

Blood clot and/or a pulmonary emboli

Arrhythmia

Pacemaker

Defibrillator

Anemia

Asthma

Emphysema

COPD

Hepatitis

HIV/AIDS

Lupus or other auto immune disease

Fibromyalgia

Trouble passing urine or take Flomax or Avodart

Chronic liver disease (fatty liver or cirrhosis)

Diabetes (Type 1)

Diabetes (Type 2)

Thyroid disease

Arthritis

Depression

Anxiety

ADD/ADHD

Cancer

Other

NONE

Birth Control Method *

Applies to Females only

Menopause

Hysterectomy

Tubal Ligation

Birth Control Pills

Vasectomy

Other

None

Preventative care *

List all that apply

Medical/GYN Exam in the last year

Mammogram in the last 12 months

Bone Density in the last 12 months

Pelvic ultrasound in the last 12 months

None

Describe your pain *

Select all that apply

None

Sharp

Stabbing

Throbbing

Burning

Aching

Numbness

Tingling

Other

Chronic Pain Assessment *

Have you ever been diagnosed with any of the following conditions?

Chronic Pain

Arthritis or joint pain

Neck Pain

Lower Back Pain

Facial Pain or Trigeminal Neuralgia

Migraines

Sciatica

Fibromyalgia

Chronic Fatigue Syndrome

None

Pain Therapy Questionnaire *

List all therapies you have utilized to treat your pain or select none

Prescription Pain Medications

Opioid Medications (Ex. Hydrocodone, Oxycodone, Codeine)

NSAIDS (ex. Aleve, Advil, Motrin, Naproxen, ect..)

Tylenol

Other over the counter medication

Chiropractic Care

Acupunture

Physical Therapy

TENS unit

Injections

Surgery

Massage

Mental Health

None