St John - Clark Pain Treatment Center

St. John - Clark Pain Treatment Center
Medical Intake Form
By coming here you have taken a big step toward improving and optimizing your health. Please fill out the following information as accurately as possible. Our intake form is thorough because we are thorough in our assessment and treatment. It is the only way to accurately determine how the various systems of your body are working together so that we can provide you with the personalized treatment that you deserve. It is our honor and pleasure to serve you.
Full Name*
First NameLast Name
Address*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Email*
example@example.com
Cell Phone Number*
Work Phone Number
Home Phone Number
Age
Years
Birth Date*
MonthDayYear
Date
Gender
MaleFemaleOther
Occupation
Marital Status
MarriedSingleDivorced
Spouse's Name (if applicable)
Spouse's Occupation (if applicable)
How did you hear about St. John - Clark Pain Treatment Center?*
Please circle your area(s) of experienced pain
Have you ever been treated for the same condition?*
YesNo
Were you admitted to the hospital?
YesNo
Describe how it feels:*
(aching, cramping, dull, sore, deep, sharp, shooting, stabbing, stinging, tingling, burning, numbness, radiating - if so, where?)
How did the pain first start? How did it start this time, if this is not the first time you've felt it?*
Sudden or gradual onset? Mechanism of injury?
How often does it bother you?
ConstantlyEvery nightEverydayEvery weekEvery monthOther
How long does it last once it's there?*
AlwaysMinutesHoursNo pattern
What specifically makes it worse?
Certain movements/activitiesTime of dayUpon wakingSleepingPositionNothing
Do you have a diagnosis from a doctor?
If yes, list it and the name of the doctor.
Other therapies/remedies tried? Results?
Have you ever had any surgeries? Were they beneficial?
List any other health problems for which you are being treated:*
Do you have any pre-existing injuries that relate to this present injury?*
YesNo
If yes, please explain:
Current medications:
Activities of Daily Living
The objective of this section is to get a sense of what types of activities, movements, postures, positions, and exercise you engage in on a regular basis. This section is also intended to get a feel for the intensity and frequency with which you perform these activities.
Work Duties:
Household Duties:
Exercise, Activities, Hobbies:
Sleeping Position:
What do you believe caused, or is causing this condition?
On a scale of 1 - 10, how much effort are you willing to put in to achieve maximum healing?
12345678910
On a scale of 1-10, choose the level of stress you are experiencing on a regular basis:
12345678910
Medical History
ArthritisAllergies/Hay FeverAsthmaAlcoholismAlzheimer's DiseaseAutoimmune DiseaseBlood Pressure ProblemsBronchitisCancerCarpal Tunnel SyndromeCholesterol, elevatedChronic Fatigue SyndromeCirculatory ProblemsColitisDepressionDental ProblemsDiabetesDiverticular DiseaseDrug AddictionEating DisorderEpilepsyEmphesymaEnvironmental SensitivitiesEyes, ears, nose, throat problemsFibromyalgiaFood IntoleranceGastroesophageal RefluxGenetic DiseaseGlaucomaGoutHeart DiseaseInfectionIrritable Bowel SyndromeKidney or Bladder DiseaseLearning DisabilitiesLiver or Gallbladder Disease (stones)Mental IllnessMigraine HeadachesNeurological ProblemsObesityOsteoporosisPneumoniaSeasonal Affective DisorderSexually Transmitted DiseaseSkin ProblemsSinus ProblemsStrokeThyroid TroubleTuberculosisUlcerUrinary Tract InfectionVaricose VeinsOther
Medical (Men)
BPHInfertilityProstate CancerDecreased Sex DriveOther
Medical (Women)
Medical (Women)
InfertilityMenstrual IrregularitiesEndometriosisFibrocystic BreastsPMSFibroids/Ovarian TumorsBreast CancerVaginal InfectionsDecreased Sex DriveSTDC-SectionMenopauseSurgical MenopauseOtherPelvic Inflammatory Disease
Age of first period
Date of last gynecological exam
MonthDayYear
Date
Form of Birth Control
Date of last mammogram
MonthDayYear
Date
Date of last PAP
MonthDayYear
Date
Number of children
Date of last menstrual cycle
MonthDayYear
Date
Number of Pregnancies
Length of cycle
(days)
Any recent changes in normal menstrual flow?
(e.g. heavier, large clots)
Family Medical History
Arthritis, rheumatoidAsthmaAlcoholismAlzheimer's DiseaseCancerDepressionDiabetesDrug AddictionEating DisorderGenetic DiseaseGlaucomaHeart DiseaseLearning DisabilitiesMental IllnessMigraine HeadachesNeurological DisordersObesityOsteoporosisStrokeSuicideOther
Tobacco
YesNo
If yes, how many cigars or cigarettes a day?
Alcohol
YesNo
If yes, what type and how many drinks per week?
Caffeine
YesNo
If yes, how many 8 oz cups of coffee per week?
If yes, how many 8 oz cups of tea per week?
If yes, how many cans of caffeinated soda per week?
Other sources of caffeine and frequency of consumption:
How many glasses of water per day?
Exercise
5-7 days per week3-4 days per week1-2 days per week45 minutes duration or more per workout30-45 minutes duration per workoutLess than 30 minutesWalkRun, jog, jump ropeWeight liftingSwimBoxing/Martial ArtsYoga
Nutrition and Diet
Mixed food diet (animal and vegetable sources)VegetarianVeganFat RestrictionCarbohydrate RestrictionSalt RestrictionThe Zone DietCalorie Restriction
Specific Food Restriction
DairyCornEggsGlutenNutsSoyAdded SugarOther
Food Frequency
Servings per day
Fruits
Dark green or deep yellow/orange vegetables
Grains
Beans/Peas/Legumes
Dairy/Eggs
Meat, Poultry, Fish
Current Supplements
MultivitaminsVitamin CVitamin EEPA/DHAEvening Primrose/GIACalciumPotassiumMagnesiumZincMineralsProbioticsDigestive EnzymesAmino AcidsCoQIOAntioxidantsHerbs (teas)Herbs - extractsChinese HerbsAyurvedic herbsHomeopathyBach FlowersProtein ShakesSuperfoodsLiquid Meals (e.g. Ensure)KetonesOther
Eating Habits
Skip BreakfastTwo meals/dayOne meal/dayGraze (small frequent meals)Food RotationEat constantly whether hungry or notGenerally eat on the runAdd salt to food
Would you like to:
Have more energyBe strongerHave more enduranceIncrease your sex driveBe thinnerBe more muscularImprove your complexionHave stronger nailsHave healthier nailsBe less moodyBe less depressedBe less indecisiveFeel more motivatedBe more organizedImprove memoryThink more clearly and be more focusedDo better on tests in schoolNot be dependent on MedicationBe free of painStop using laxatives or stool softenersSleep betterHave agreeable breathHave stronger teethGet less colds/flusGet rid of your allergiesReduce your risk of inherited disease tendencies
Terms and Conditions
Release and Indemnification
I hereby authorize St. John - Clark Pain Treatment Center to provide any and all information, copies, or records to any clinic, physician, lawyer, insurance company, or workman's compensation fund as deemed necessary. A copy of this authorization shall be considered as valid as the original.
I hereby authorize any physician to release any and all information and copies of all records to St. John - Clark Pain Treatment Center as deemed necessary for treatment. A copy of this authorization shall be considered as valid as the original.
I give permission that photographs and video footage may be taken of me or my X-rays, CAT, or MRI scans during the course of treatment at St. John - Clark Pain Treatment Center. These photographs are strictly to be used for treatment planning, or education for other healthcare practitioners and will not be displayed anywhere else without my written permission.
24 Hour Cancellation Policy
I understand that there is a 24 hour cancellation policy for scheduled appointments. Cancellation of a scheduled appointment must be made by calling St. John - Clark Pain Treatment Center. Failure to cancel without the minimum notice will result in the full charge for the cancelled or missed appointment. Cancellation for Mondays and the day after holidays must be made on the prior business day during normal business hours. Payment for the entire amount of the scheduled appointment will be expected regardless of the patient's arrival time.
I agree to the above terms & conditions*
YesNoOther
Signature*
Clear
Should be Empty:

St. John - Clark Pain Treatment Center

Medical (Women)

Food Frequency