First Name
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Last Name
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Phone
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Email
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Preferred Clinic Location
Bozeman
Billings
Helena
Missoula
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Today's Date
Your Birthday
Address
City
State
Zip
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 type of natural treatment?
Yes
No
What joint problems are you most concerned about?
What have you done to treat the above problems?
Have your symptoms Improved, Stayed the Same or Gotten Worse with treatment?
Improved
Stayed the same
Gotten Worse
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?
1
2
3
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5
6
7
8
9
10
Health Issues (click all that apply)
Headaches
Neck Pain
Mid Back Pain
Low Back Pain
Difficulty Sleeping
Fatigue
Heart Issues
Stomach/Reflux Issues
Lung Issues
Nerve Issues/M.S.
Diabetes
Rheumatoid Arthritis
Peripheral Neuropathy
Infections
Kidney/Bladder Issues
Reproductive Issues
Allergy to Sulfa
I am a Smoker
I consume alcohol
Hip Problems ?
None
Left
Right
Both
Knee Problems ?
None
Left
Right
Both
Leg Problems ?
None
Left
Right
Both
Shoulder Pain ?
None
Left
Right
Both
Arm or Hand Pain ?
None
Left
Right
Both
Foot/Ankle Problems ?
None
Left
Right
Both
Stiffness ?
If Yes, where are you stiff? (If None, type NA)
Numbness or Tingling
If Yes, where is the numbness or tingling? (If None, type NA)
Degeneration ?
If Yes, where is the degeneration? (if None, type NA)
Blood Pressure Issues ?
High
Low
List all Allergies:
List all Surgeries that you have had:
Do you Exercise?
Yes
No
How Much/Often?
List any Prescription Drugs you are currently taking:
List any Supplements you are currently taking
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