Form #2

Reason for Visit

Please fill out all fields to the best of your ability

Name*
First Last
Email*
Enter Email Confirm Email
Phone*
Age*
Please enter a number from 18 to 99.
Sex*
- Male
- Female
Reason for Consulting This Office
Check all that apply:*
- Pain
- Sports Injury
- Work
- Auto Accident
- Home Accident
- For Optimal Health and Performance
Describe what brought you to the clinic:*
Changes in Health History since last visit:*
Date of onset:*
MM slash DD slash YYYY
Have you had:
- X-Rays
- MRI
- CTs taken of the area mentioned above?
Describe the pain
Check all that apply:*
- Deep
- Superficial
- Dull
- Sharp
- Achy
- Throbbing
- Stabbing
- Shooting
- Burning
- Piercing
What % the day do you have pain?*
- 0-25%
- 25-50%
- 50-75%
- 75%-100%
Have you had this problem in the past?*
- YES
- NO
If yes, is it the*
- Same
- Worse
- Better than before
Does it affect your regular activities?*
- YES
- NO
If yes, how so?*
When do you feel the best?*
- Morning
- Afternon
- Evening
When do you feel the worst?*
- Morning
- Afternon
- Evening
Severity of pain TODAY on a scale of 0 – 10 (0= none, 10= worst imagined):*
Severity of pain AT TIME OF INJURY on a scale of 0 – 10 (0= none, 10= worst imagined):*
Have you seen anyone else for this condition?*
- YES
- NO
If yes, who?*
What was the diagnosis?*
How have you treated yourself for this condition?*
- Select All
- Ice
- Heat
- Stretching
- Medication
- Massages
- Exercise
- Other
Please list anything that makes the condition better:*
Please list anything that makes the condition worse:*
Are you currently taking any medications, pain relievers, or supplements? Please list the dosage and reason for taking for all prescriptions and over-the-counter medicines:*
Do you have allergies?*
- YES
- NO
If yes, to what and how do you manage an allergy “attack”?*
Consent Statement*
By entering my full name in the field below, I am signing the form
Client Signature*

If the client is not yet 18 years old, a parent or guardian must sign.
Today's Date*
MM slash DD slash YYYY
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Jennifer Corey

480.747.8902

9312 E. Raintree Drive

Scottsdale, AZ 85260

Jennifer@magnoliatherapeutics.net