Muscle Spasm Treatment Intake Form
Please complete this form so we can provide you with the best possible care for your muscle spasm treatment.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Emergency Contact Name and Relationship
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Describe your muscle spasm symptoms (location, duration, severity, triggers)
*
When did your symptoms start?
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Do you have any of the following medical conditions?
*
Neuromuscular disorder
Chronic pain
Arthritis
Diabetes
Heart condition
None of the above
Other
Please list all current medications (including over-the-counter and supplements)
*
Do you have any allergies?
*
No known allergies
Medications
Latex
Foods
Other
Have you previously received treatment for muscle spasms?
*
Yes
No
If yes, please describe prior treatments and their effectiveness
Signature
*
Submit Intake Form
Submit Intake Form
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