Medical History

First Name *

Last Name *

Street Address *

Address Line 2

City *

State * 🛈

Zip Code *

International State or Region

Country *

Cell Number *

Email Address *

Occupation? *

Sex:

Male

Female

How did you hear about us? *

Date of Birth: *

Age? *

Marital status *

Single

Married

Divorced

Widowed

What are your health goals? *

Please list your hobbies. *

Are you still able to perform your hobbies? *

Yes

No

Describe Your Pain & Symptoms

What areas of your body hurt? *

Is your condition worse in: *

The Morning

Evening

Constant All the Time

Does not Apply

How long have you suffered with this problem? *

Is your condition getting: *

Better

Worse

The Same

Did anything contribute to the onset of your condition? *

Describe your symptoms: *

When it's at it's worse, rate the severity of your discomfort. (1 is mild - 10 is severe) * 🛈

Activities of Daily Living

Check the activities that aggravate your condition: *

What have you tried doing to resolve your problem that did not work? *

How does your problem interfere with work, family, hobbies, or life in general? *

When your problem is at it's worse, how does it make you feel? *

Are you setting this virtual consult to: *

Begin care, if doctor feels he can help you	Just explore treatment options
Obtain a second opinion	Other: Other:

Sharp	Dull	Throbbing	Aching	Shooting	Numbness
Burning	Tingling	Cramping	Stiffness	Swelling

Sitting	Standing	Walking	Bending	Lying Down
Getting Dressed	Sports	Work	Sleep	Other Other