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Joint Repair Clinic of MT Consultation

Name:

Date:

Age:

Address:

City:

State:

ZIP:

Cell Phone Number:

Email:

Occupation:

Spouse first name:

Spouse phone #:

Do you currently have active cancer and/or you currently treating cancer?

Are you expecting insurance to pay for this?

What problem are you the most frustrated about that we can help you with?

Other problems that you would like our help with?

What have you done to treat the above problems?

How is that treatment system working?

Are you worried that your problem is getting worse?

Are you angry that nobody has been able to get your problem fixed?

Have your symptoms?

What makes your condition Worse?

What makes your condition Better?

List the doctors that you have seen for these problems, treatment you received:

How would you rate your pain in the last week?

If you had to accept some level of pain after completion of treatment, what would be an acceptable level?

Do you have pain or problems with?

Headache

How often & long?

Where?

Dr. Notes

Neck Pain

How often & long?

Where?

Dr. Notes

Mid Back Pain

How often & long?

Where?

Dr. Notes

Low Back Pain​​​​​​​

How often & long?

Where?

Dr. Notes

Difficulty Sleeping​​​​​​​

How often & long?

Where?

Dr. Notes

Stiffness​​​​​​​

How often & long?

Where?

Dr. Notes

Stiffness​​​​​​​

How often & long?

Where?

Dr. Notes

Numbness/Tingling​​​​​​​

How often & long?

Where?

Dr. Notes

Shoulder Pain​​​​​​​

How often & long?

Where?

Dr. Notes

Degeneration​​​​​​​

How often & long?

Where?

Dr. Notes

Fatigue​​​​​​​

How often & long?

Where?

Dr. Notes

Arm/Hand problems​​​​​​​

How often & long?

Where?

Dr. Notes

Hip problems​​​​​​​

How often & long?

Where?

Dr. Notes

Leg problems​​​​​​​

How often & long?

Where?

Dr. Notes

Knee problems​​​​​​​

How often & long?

Where?

Dr. Notes

Foot problems​​​​​​​

How often & long?

Where?

Dr. Notes

Heart/circulation issues​​​​​​​

How often & long?

Where?

Dr. Notes

Stomach/Reflux​​​​​​​

How often & long?

Where?

Dr. Notes

Lungs​​​​​​​

How often & long?

Where?

Dr. Notes

Nerves/ M.S.​​​​​​​

How often & long?

Where?

Dr. Notes

Diabetes

How often & long?

Where?

Dr. Notes

Cancer​​​​​​​

How often & long?

Where?

Dr. Notes

Rheumatoid Arthritis​​​​​​​

How often & long?

Where?

Dr. Notes

Peripheral Neuropathy​​​​​​​

How often & long?

Where?

Dr. Notes

Infections​​​​​​​

How often & long?

Where?

Dr. Notes

Blood Pressure​​​​​​​

How often & long?

Where?

Dr. Notes

Colon (const/diarrhea)​​​​​​​

How often & long?

Where?

Dr. Notes

Kidney/Bladder​​​​​​​

How often & long?

Where?

Dr. Notes

Reproductive organs​​​​​​​

How often & long?

Where?

Dr. Notes

Are you allergic to sulfa?

Other Allergies?

Surgeries that you have had:

Accidents/Broken Bones:

Smoke?

How Much/Often?

Drink?

How Much/Often?

Exercise?

How Much/Often?

Family History of health problems:

List the prescription drugs you are currently taking (or you may attach a list):

Name

Condition Treating

Dose and Frequency

List all nutritional supplements (vitamins, herbs, homeopathies, etc.):

Name

Reason for Taking

Dose and Frequency

This is a confidential record of your medical history. The doctor reserves the right to discuss this information with the medical professionals. Copies of this record can only be released with your specific authorization. I authorize Joint Repair Clinic of Montana of MT to contact me through phone, text, and email.

Name

Signature

Date

WeC@re406! none 8:00am - 10:00am, 03:00pm - 06:00pm, Closed 8:00am - 10:00am, 03:00pm - 06:00pm, 03:00pm - 06:00pm 08:00am - 10:00am Closed Closed chiropractor # # # https://www.google.com/maps/place/Joint+Repair+Clinic+of+Montana/@45.6874032,-111.0617983,15z/data=!4m5!3m4!1s0x0:0x4c4ca2ad9718693c!8m2!3d45.6874032!4d-111.0617983