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Dr. Matt The Acrobat
Home
About
Mission
Bio
Testimonials
Facilities
Appointments
Services
Your Service Options
Manual Therapy
Therapeutic Movement Flow
TeleHealth
Forms of Payment
Prehab Program
Forms
Intake
Contact
Intake Form
Personal Information
Name
*
First Name
Last Name
Date of Birth
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Primary Phone #
*
(###)
###
####
Secondary Phone #
(###)
###
####
Email
*
Occupation
How did you hear about Dr. Matt the Acrobat?
Emergency Contact Information
Name
*
First Name
Last Name
Relationship
*
Primary #
*
Secondary #
(###)
###
####
Email
Medical History
Do you have a history of the following conditions?
Asthmas/Bronchitis/Emphysema
Yes
No
High Blood Pressure
Yes
No
Heart Disease/Angina
Yes
No
Do you have a pacemaker?
Yes
No
Blood Clot
Yes
No
Infectious Diseases
Yes
No
Thyroid/Goiter Problems
Yes
No
Cancer
Yes
No
Arthritis
Yes
No
Stroke/TIA
Yes
No
Diabetes
Yes
No
Gout
Yes
No
Anemia
Yes
No
Allergies
Yes
No
Osteoporosis
Yes
No
Hernia
Yes
No
Anxiety/Depression
Yes
No
Joint Replacement
Yes
No
List any other conditions not provided above:
List All Surgical Procedures you have had:
Are you currently pregnant?
Yes
No
Do you smoke cigarettes?
-
Yes (Every day)
Yes (greater than 5 cigarettes a week)
Yes (less than 5 cigarettes a week)
No
Do you drink alcohol
-
Yes (Greater than 5 drinks per week)
Yes (Less than 5 drinks per week)
Yes (On special Occasions)
No
Do you do drugs?
-
Yes
No
How often do you exercise a week?
0 to 1 hour
1 to 3 hours
3 to 5 hours
5 to 10 hours
Greater than 10 hours
Have you recently had any of the following symptoms?
Shortness of Breath
Yes
No
Chest Pain
Yes
No
Dizziness or Fainting
Yes
No
Vision or Hearing Problems
Yes
No
Bowl or Bladder Problems
Yes
No
Sudden Weight Loss or Gain
Yes
No
Fever/Nausea/Vomiting
Yes
No
Please list all medications that you are currently taking:
Reasons that bring you to Dr. Matt the Acrobat
What are your main concerns with your health or wellness that bring you to Dr. Matt the Acrobat?
Onset Date
(rough estimate, or exact date)
Onset of symptoms
-
Sudden
gradual
List any previous treatments that you have had due to your health concerns:
Physical Therapy, Massage, Chiropractics, Acupuncture, etc...
Have you had imaging for your specific injury? If applicable, please provide results.
Please specify: X Ray, MRI, CT Scan, Bone scan, EMG, etc...
What is your pain at the present time? (scale of 0 to 10)
0 = no pain, 10 = worst possible pain
0
1
2
3
4
5
6
7
8
9
10
What is your pain at its worst? (scale of 0 to 10)
0 = No pain, 10 = Worst possible pain
0
1
2
3
4
5
6
7
8
9
10
Describe your pain:
Pick one of the following
Dull
Sharp
Aching
Shooting
Radiating
Tingling/Numbness
Stabbing
Sore
Burning
When is your pain the worst?
Morning
Afternoon
Evening
No change throughout the day
List any movements, activities and positions that make your symptoms worst:
List any movements, activities and positions that make your symptoms better:
What activities do you have the most difficulty doing due to your symptoms?
What are your primary goals for coming to see Dr. Matt the Acrobat?
Do you consent to the Terms and Conditions Laid Out in the Liability Form?
http://www.drmattacrobat.com/liability
Yes
No
Thank you!