Date of Onset/Injury *

MM

DD

YYYY

Date Date of Surgery

MM

DD

YYYY

Have you had any treatments or are you currently seeing any of the following for your current injury?

Physical Therapist

Medical Doctor

Chiropractor

Psychiatrist/Psychologist

Osteopath

Masseuse

Have any diagnostic tests have been performed for this injury?

X-rays

MRI

EMG

CT Scan

Other

Please check all that apply

Cancer

Heart Conditions

Diabetes

High Blood Pressure

Stroke/TIA

Rheumatoid Arthritis

Osteoarthritis

Parkinson’s

Polymyalgia

Multiple Sclerosis

Lupus

Epilepsy/Seizures

Fibromyalgia

Chronic Fatigue

Numbness/Tingling

Osteoporosis

Headaches/Migraines

Bulging Disks

Tuberculosis

Skin Allergies/Rashes

Hepatitis

Weakness in your legs

Bowel or bladder troubles

Blurred vision or nausea

Dizziness with neck mov’t

Other