Consultation Request Form
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First Name
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Address
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City
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State
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Zip Code
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Last Name
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Date of Birth
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Height
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Weight
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Mobile Number
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Email Address
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Marital Status
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Married
Single
Widowed
Spouse's Name
Spouse's Phone Number
Employed?
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Yes
No
# of Years Employed
Name of Employer
General Symptoms (check all that apply)
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Foot Pain
Hand Pain
Low Back Pain
Neck Pain
Foot Numbness
Hand Numbness
Diabetes
High Cholesterol
High Blood Pressure
Pacemaker/Defibrillator
Herniated Disk
Bulging Disk
Spinal Stenosis
Degenerative Disc
Spinal Stenosis
Vascular Problems
Leg Pain
Plantar Fasciitis
Morton's Neuroma
Cancer
Chemotherapy
Arthritis in Hand
Arthritis in Feet
Implanted Cord/Bladder Stimulator
Sciatica
Pinched Nerve
Poor Circulation
Joint Replacement
Foot Surgery
Poor Wound Healing
Excessive Thirst or Urination
Hip Pain
Knee Pain
Organ Transplant
If you have cancer, what is the location?
Has it metastasized?
Yes
No
Have you done chemotherapy or radiation?
Chemotherapy
Radiation
Both
Other treatment options?
Please list the issues you are interested in correcting in the order of importance
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Approximately how long have you noticed these symptoms?
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Do you smoke?
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Yes
No
If yes, how many cigarettes daily?
Do you drink?
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Yes
No
If yes, how many drinks daily?
Do you exercise daily?
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Yes
No
If yes, how much exercise daily?
Name of Primary Care Provider
Phone Number of Primary Care Provider
List any previous surgeries with the date they occurred
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List all allergies or sensitivities to food, medication, etc.
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How do you react to those allergies?
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List any prescription drugs you are taking along with dosage and frequency.
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List all nutritional supplements (vitamins, herbs, homeopathies, etc.) along with dosage and frequency.
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