Quick Patient Intake

Name

Date of birth

Email address

Mailing address

Cell phone

Home phone

List areas of pain or tension

Stress level (10 is highest and 1 is lowest)
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Pain level (10 is highest and 1 is lowest)
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Energy level (10 is highest and 1 is lowest)
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How long have you been experiencing pain?

Allergies and Medications

Exercise activities

Comments