Patient Intake Form Contact Details First Name * Last Name * Middle Initial How did you hear about us? * Facebook Instagram Google Website Van Yelp Dr. Early Dr. Gans Other Other Reference * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Cell Phone * Home Phone Date of Birth * Email * Contraindications For ARP:Are you pregnant? * Yes NoAny pacemaker or ICD? * Yes NoAny history of blood clots? * Yes No Text Present Condition Where is the location of your pain? * Describe your complaint / symptoms: * Rate the intensity of your pain, on a scale 0 to 10, 10 being the worst possible pain: * 1 2 3 4 5 6 7 8 9 100-1: Pain | 2-3: Mild Pain | 4-5: Moderate Pain | 6-7: Severe Pain | 8-9: Very Intense Pain | 10: Worst Possible Pain When did your complaint/symptoms begin? * What was the cause of your symptoms? * How have the symptoms progressed? * What treatments have you done? * Massage Surgery Medication Chiropractic Physical Therapy Acupuncture Rest/Ice /Compress/Elevate OtherCheck all that apply Other Treatments * What activity bothers you the most? * What activity lessens your symptoms? * What does your pain feel like? * Aching Burning Numbness Pins and Needles Stabbing / Sharp OtherCheck all that applyMedical History Primary Care Physician * Chiropractor Orthopedist Do you have any medical records that have been created regarding your symptoms you are being seen for today? * Yes No Name of Physician: * What was the result? * Please list any allergies: * Diagnostic TestsHave you had any diagnostic tests performed? * MRI CT X-Rays Lab Work Functional Testing NCV/EMG OtherCheck all that applyTruthful RepresentationBy initialing the following the following statement "ALL INFORMATION IS TRUE" I hereby state that all the information I have provided is true, correct and complete. If more information about my condition becomes known, I will tell the doctor when possible so it can be added to my record. ALL INFORMATION IS TRUE * signature keyboard Clear Your InitialsTreatmentI understand while Dr. Earley and her staff agree to treat me, she cannot personally guarantee any results. I understand I will be advised of advantages and complications, if any, as well as other treatment options should they become necessary. I UNDERSTAND * signature keyboard Clear Your InitialsRelease of LiabilityIn conjunction with my ARP Wave treatment at Huebner Chiropractic and Neuro Sports Performance & Rehab, as part of the consideration for my treatment, I, my heirs, executors, spouse, assigns, offspring, agents and representatives expressly release, hold harmless and indemnify Huebner Chiropractic/Neuro Sports Performance & Rehab owners, agents, employees, representatives, assignees, and licensees from all liability for any treatments given. I AGREE * signature keyboard Clear Your InitialsConsent to TreatmentBy signing below, I hereby give my consent to treatment. Signature * signature keyboard Clear Today's Date * Submit
