Joint Rejuvenation & Spine Intake Form

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Intake Form

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    About You


    Date of Birth*



    Emergency Contact

    Medical History

    Personal History*:

    Family History*:

    Check all that apply:*

    Do you exercise?*


    Area of Concern*:

    Side Affected*


    When did the pain start?*

    How quickly do symptoms appear?*:

    Does the Pain Radiate?*

    How does the pain feel?*:

    Check any of the following that reduce pain:*

    Treatment History

    Check any medications you are taking:*

    Any treatments you have previously tried:*

    Previous Diagnostics:*

    I have answered the questions above and read and understand the following:*

    Which of the following refers to you:*