Appointment - Intake Form

 

 

 No More Pain - The ARP Way

CAN: 1.416.770.1757      USA: 1.206.497.1500      Tool Free Fax:  1.855.853.9659  (USA, CAN & Latin)


ALL INFORMATION IS KEPT STRICTLY CONFIDENTIAL

SECTION #1
Preset Field - Do Not Change:

Your Full Legal Name:

Please check all present symptoms related to your current condition:
 

Are you pregnant:     (If YES, not qualified)
 

Any pacemaker or ICD: (If YES, not qualified)
 

Do you have a Blood clot or any history of blood clots: (If YES, not qualified)

NOTE: If you answered YES to any of the above questions we can not help you.
 

Where Is The Location Of Your Pain:
Rate The Intensity Of Your Pain When Doing A Movement That Bothers You:

-----------------------------------------------------------------------------------------------------------------

Preset Field - Do Not Change:
When did your complaint/symptoms begin:
Describe your complaint/symptoms:   

Where is the location of your pain:     

What does your pain feel like:
           
What was the cause of the symptoms:

What activity bothers you the most:    

What activity lessens your symptoms: 

How have symptoms progressed:        


What treatments have you done (check all that apply):
Massage    Medication    Physical Therapy    Rest / Ice / Compression
Surgery Chiropractic Alternative

------------------------------------------------------------------------------------------------------------------

Preset Field - Do Not Change:

Have you seen a doctor because of your current condition:   
If so, what was the result:

Do you have any allergies, if so list them:
  

------------------------------------------------------------------------------------------------------------------

Preset Field - Do Not Change:
Have you had any diagnostic tests performed by any Doctors (check all that apply):
MRI    X-Rays    Lab Work    Functional Testing   Psychological Testing    Electro diagnostics    Others)
If so, what were the results of the test :

Are there any additional comments about your condition that you feel would be important for us to know:


SECTION #2

Year of Birth: Today's Date:
Home Address :
 City :    Prov :   Zip :
Home Phone :
Work Phone : Cell Phone :  
Best Time To Call To Setup An Appointment With You:
Best Number To Call:
Sex:
E-mail:


Press this button to submit your information:
If you do NOT agree to ALL of the terms and conditions of this agreement above please press the HOME button.