First Name
*
Last Name
*
Phone
*
Email
*
Preferred Clinic Location
Bozeman
Billings
Helena
Missoula
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Today's Date
Birthday
Age
Address
City
State
Zip
Cell Phone Number:
Occupation
Spouse first name:
Do you currently have active cancer and/or are you currently treating cancer?
Yes
No
Are you aware that insurance does not cover this?
Yes
No
What Problem Are You The Most Frustrated About That We Can Help You With?
Other problems that you would like our help with?
What have you done to treat the above problems?
How is that treatment system working?
Are you worried that your problem is getting worse?
Yes
No
Have your symptoms
Have your symptoms
Improved
Stayed the same
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What makes your condition Worse?
What makes your condition Better?
How would you rate your pain in the last week?
NO PAIN
1
2
3
4
5
6
7
8
9
10
WORST PAIN POSSIBLE!
If you had to accept some level of pain after completion of treatment, what would be an acceptable level?
NO PAIN
1
2
3
4
5
6
7
8
9
10
WORST PAIN POSSIBLE!
Headache
Yes/No
How often & long?
Where?
Dr. Notes
Neck Pain
Yes/No
How often & long?
Where
Dr. Notes
Mid Back Pain
Yes/No
How often & long?
Where?
Dr. Notes
Low Back Pain
Yes/No
How often & long?
Where?
Dr. Notes
Difficulty Sleeping
Yes/No
How often & long?
Where?
Dr. Notes
Stiffness
Yes/No
How often & long?
Where?
Dr. Notes
Numbness/Tingling
Yes/No
How often & long?.
Where?
Dr. Notes
Shoulder Pain
Yes/No
How often & long?
Where?
Dr. Notes
Degeneration
Yes/No
How often & long?
Where?
Dr. Notes
Fatigue
Yes/No
Value How often & long?
Where?
Dr. Notes
Arm/Hand problems
Yes/No
How often & long?
Where?.
Dr. Notes
Hip problems
Yes/No
How often & long?
Where?
Dr. Notes
Leg problems
Leg problems
How often & long?
Where?
Dr. Notes
Knee problems
Yes/No
How often & long?
Where?
Dr. Notes
Foot problems
Yes/No
How often & long?
Where?
Dr. Notes
Heart/circulation issues
Yes/No
How often & long?
Where?
Dr. Notes
Stomach/Reflux
Yes/No
How often & long?
Where?
Dr. Notes
Lungs
Yes/No
How often & long?
Where?
Dr. Notes
Nerves/ M.S.
Yes/No
How often & long?
Where?
Dr. Notes
Diabetes
Yes/No
How often & long?
Where?
Dr. Notes
Cancer
Yes/No
How often & long?
Where?
Dr. Notes
Rheumatoid Arthritis
Yes/No
How often & long?
Where?
Dr. Notes
Peripheral Neuropathy
Yes/No
How often & long?
Where?
Dr. Notes
Infections
Yes/No
How often & long?
Where?
Dr. Note
Blood Pressure
Yes/No
How often & long?
Where?
Dr. Notes
Kidney/Bladder
Yes/No
How often & long?
Where?
Dr. Notes
Reproductive organs
Yes/No
How often & long?
Where?
Dr. Notes
Are you allergic to sulfa?
Yes
No
Other Allergies?
Surgeries that you have had:
Smoke?
Yes
No
How Much/Often?
Drink?
Yes
No
How Much/Often?
Exercise?
Yes
No
How Much/Often?
List the prescription drugs you are currently taking (or you may attach a list):
Name
Condition Treating
Dose and Frequency
List all nutritional supplements (vitamins, herbs, homeopathies, etc.):
Name
Reason for Taking
Dose and Frequency
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