Patient Information

Patient Information

Your Name (required):

Your Address(required):

City: Zip Code: DOB:

Phone-Home: Work or Cell:

Your Email (required):

Occupation:

Employer:

How did you hear about Body Dynamic?

Spouse Name: DOB:

Emergency Contact or Parent/Guardian (if under 18):

Name: Relationship to you:

Address &/or Phone #:

Employer: Business Phone:

Health/Fitness Information

How would you describe your overall level of health?
ExcellentVery GoodGoodFairPoor

On a consistent basis, how many times a week do you exercise?

What type of exercise?

Do you smoke? If so, how much/how often?

Any Allergies? (please list)

Reason you are here today?

Are you currently experiencing pain? Where?

Date of injury or onset of pain?

Have you had any surgical procedures or other types of treatment for above injury/pain?

Do you feel it helped?

Are you currently experiencing any loss of function or work related issues due to above pain?

Are you currently under a physician's care?

Name of Physician(s):

Have you had any tests for this problem?

X-Ray   Date:
CAT Scan   Date:
Bone Scan   Date:
MRI   Date:
EMG   Date:
Other:

Medical History(Self Only)

Cancer   Seizures
Diabetes   Tuberculosis
Arthritis   Lung Disorders
Joint Pain   Chronic Cough
Swelling of Legs/Ankles   Shortnes of Breath
Back Problems   Asthma
Heart Disease   Weight Loss
Pacemaker   Thyroid Disorder
High Blood Pressure   Surgery
Headaches   Bleeding Disorders
Fainting   Serious Injuries
Stroke   Hospitalizations
Dizziness   Other

If you answered yes, please explain:

Please list any medications you are currently taking:

For women, are you pregnant?

Assignment of Benefits

Patient's Name:

Primary Insurance ID:

Secondary Insurance ID:

Consent to Treatment

Cancellation Policy