Patient's Full Name (First, Middle, Last)
Age
*
Email Address
Referring Physician (if applicable)
How did you hear about us? Please be specific
*
Cancer
*
-
Yes
No
If yes please describe
Chemotherapy or Radiation Therapy
*
-
Yes
No
If yes to chemotherapy or radiation therapy please describe
Diabetes
*
-
Yes
No
If yes to Diabetes please describe
Diabetic Retinopathy
*
-
Yes
No
If yes to diabetic retinopathy please describe
Heart Problems
*
-
Yes
No
If yes to heart problems please describe
History of Neck Problems
*
-
Yes
No
If yes to history of neck problems please describe
Macular Degeneration
*
-
Yes
No
If yes to macular degeneration please describe
Peripheral Neuropathy
*
-
Yes
No
If yes to peripheral neuropathy, where?
Rheumatoid Arthritis
*
-
Yes
No
If yes to rheumatoid arthritis please describe
Stroke
*
-
Yes
No
If yes to stroke please describe
Vision Problems
*
-
Yes
No
If yes to vision problems please describe
Are you currently taking any medications?
*
-
Yes
No
If yes, please list medications
Have you had any surgeries?
*
-
Yes
No
If yes, please list all surgeries
Hobbies/Activities you can't perform because of symptoms
*
What is you primary complaint? Describe your symptoms
When and how did your problem begin?
*
If you are having dizziness: if 0 is no dizziness and 10 is severe dizziness, please select the number corresponding to the intensity of your dizziness of daily living
*
-
1
2
3
4
5
6
7
8
9
10
Frequency of symptoms (Select one)
-
Constant
Intermittent
Only happens with certain activities
Never
How long do your symptoms last?
*
-
I have no symptoms
Minutes
Hours
Days
Constant
What increases symptoms?
What decreases symptoms?
Are symptoms positional?
-
Yes
No
If yes, what positions worsen/cause symptoms?
What positions improve symptoms?
Do you have a history of vertigo?
-
Yes
No
If yes, what are the circumstances?
In the last year, have you been admitted to the hospital or have undergone a medical/surgical procedure?
-
Yes
No
If yes, what for?
Do you have neck pain?
*
-
Yes
No
Do you have any limitations in neck range of motion?
*
-
Yes
No
Are you currently seeing a chiropractor?
*
-
Yes
No
Do you have a history of headaches/migraines?
*
-
Yes
No
Tests performed by MD for this condition
Do you feel you are at risk of falling?
*
-
Yes
No
If Yes, if 0 is a low risk, and 10 is a high risk, please select the number corresponding to your fear of falling during the activities of daily living
-
1
2
3
4
5
6
7
8
9
10
Do you suffer with imbalance during daily living?
*
-
Yes
No
If yes, what are the circumstances?
Number of falls in the past 12 months
*
How did you fall (describe injuries due to falls)?
Do you use an assistive device?
*
-
Yes
No
If yes, please check all that apply
Do you live alone?
*
-
Yes
No
Did you stop working due to your current condition?
*
-
Yes
No
If yes, last date worked
Have you had previous therapy for your current symptoms?
*
-
Yes
No
If yes, please explain
At home, do you have difficulty with any physical barriers?
*
-
Yes
No
If yes, please explain
Are there any learning/phyiscal barriers that may affect your progress in therapy (hearing, vision, language, etc.)?
*
-
Yes
No
If yes, please explain
Prior level of function/activities you would like to return to
Your goals for therapy
