Form Test The Hetrick Center 1Patient Information2Current Condition & Pain3Medical History4General Health5Medications & Allergies6Consent & Signature EmailThis field is for validation purposes and should be left unchanged.Patient Name(Required) First Last Date of Birth(Required) Preferred Phone #(Required)Email Address(Required) HeightWeightBlood PressurePrimary Care Physician NamePrimary Care Physician PhoneHow did you hear about us?Emergency Contact PersonEmergency Contact NameEmergency Contact Phone History of Current ConditionWhat brings you in today?(Required)PainWhat type of pain is it? Sharp/Stabbing Aching Dull Throbbing Numbness Tingling Cramping Burning Check all that apply.Rate your pain on a scale of 0 to 100 = no pain, 10 = worst imaginable painPain: Currently 0 1 2 3 4 5 6 7 8 9 10 Pain: Average 0 1 2 3 4 5 6 7 8 9 10 Pain: At Best 0 1 2 3 4 5 6 7 8 9 10 Pain: At Worst 0 1 2 3 4 5 6 7 8 9 10 How long have you had this pain?Date of OnsetWhat makes the pain worse?What makes the pain better?Does the pain travel? If so, where?Is the pain worse at any particular time of day?The pain is getting: Better Worse Staying the Same Pain DiagramTo help us better understand the nature and origin of your complaints, please use the symbols below to mark where your symptoms are located and what type of symptoms you have in each affected area on the figures.Mark Your SymptomsPick a symbol (// Dull/Ache/Throb, ∷ Tingling, O Numbness, B Burning, C Cramping, X Sharp/Stabbing) and tap the figure to place it, or choose Draw to shade an area with your finger or mouse. Use Undo to remove the last mark.Additional Comments Please list all current and past medical conditions and note if they are under current medical treatmentConditionUnder current medical treatment? (Yes/No) Add RemoveHave you ever received x-rays? Yes No X-rays: If yes, for what?X-ray DateHave you ever received an MRI? Yes No MRI: If yes, for what?MRI DateHave you ever had other clinical tests? Angiogram Blood Tests Doppler Ultrasound Mammogram Urine / Stool Tests Bone Scan Biopsy Echocardiogram Myelogram Stress Tests Arthroscopy CT Scan EEG / EKG EMG/NCV Other Check all that apply.Other clinical testsIs your current condition related to a work injury or an automobile accident? Yes No Please make your THC provider aware immediately.Date of accident/injuryHave you ever sustained a work injury for which you received treatment? Yes No Date of work injuryPlease list surgeries, medical procedures, and/or hospitalizationsSurgery / Procedure / HospitalizationDate Add RemoveWhen was the last time you followed-up with your family physician? Do you use tobacco products? Yes No How much tobacco do you use (i.e. packs/day) and for how long?Do you drink alcohol? Yes No How much and what type of alcohol do you consume per week?Is your history significant for recreational drug use? Yes No Please describe recreational drug use.My diet is: Balanced Not Balanced Recent weight change: Gained Lost No Change How much weight?My rest is: Sufficient Insufficient Hours of sleep per nightPlease enter a number from 0 to 24.My recreation is: Sufficient Insufficient I exercise: 0 x / week 1-2 x / week 3-4 x / week 5 or more x / week My overall stress is: Severe Moderate Minimal None Medication list I have my own list of medications to attach Upload your medication listAccepted file types: pdf, jpg, jpeg, png, heic, doc, docx, Max. file size: 10 MB. Current Medications / SupplementsMedication / Supplement NameDosageFrequencyDate you started taking it Add RemovePlease list any known allergies (i.e. medications, stings, foods, Latex, etc.) and what your reaction isPlease keep us updated on any changes in medication(s) or supplement(s) that you are taking. Thank you for completing this form. The information you have provided will assist us in attending to your healthcare needs.I have read and completed all answers to the above questions to the best of my knowledge. I am aware that answering yes to any of the above questions may require me to undergo further testing prior to starting any appropriate care. I hereby give my full consent to undergo a rehabilitation exercise program or care designed for me if determined to be clinically medically necessary by my doctor or therapist. I will notify them of any changes in my health status during the duration of my program. It is also my duty to inform the doctor, therapist, or assistant of any possible complication prior to the initiation of my daily rehabilitation or treatment.Acknowledgement(Required) I have read and agree to the statement above. Your Signature(Required)Date(Required)
