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Knead To Be Fit - 3160 Southgate Commerce Blvd suite 38B, Orlando, FL 32806
Tel. 321-251-7877 Fax 321-206-8212
Personal Information
Name
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Address
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Phone Number
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Social Security Number
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E-mail
Date of Birth
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Sex
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Emergency Contact
First Name
Last Name
Phone Number
Relationship to patient
Referring Doctor
Doctor
*
First Name
Last Name
Address
Phone Number
*
Primary Insurance
Insurance
*
Policy Number
*
Group Number
*
Do you have a secondary insurance?
Yes
No
Secondary Insurance Name
Policy Number
Group Number
Patient History
Please describe your current physical complaint:
*
When and how did it occur?
*
Have you ever had any therapy for this condition before?
*
Yes
No
Have you had any special tests? (MRI, CT, X-Ray)
*
Yes
No
Please list previous tests:
On a scale of 1-10, 1 being no pain and 10 being the worst pain possible please rate your:
Current Pain
*
Please Select
No pain
1
2
3
4
5
6
7
8
9
10
Worst Pain in the Last 7 Days
Please Select
1
2
3
4
5
6
7
8
9
10
Least Pain in the Last 7 Days
Please Select
1
2
3
4
5
6
7
8
9
10
Does anything help reduce your pain?
Medical History
Do you have a Pace Maker
*
Yes
No
How many times have you fallen in the last year?
*
Please check any areas of previous injury:
*
Neck
Shoulder
Elbow
Back
Hip
Knee
Foot
None
Do you currently or have you ever had any of the following conditions:
*
Arthritis
Cancer
Asthma
Diabetes
Fibromyalgia
Heart Disease
Incontinence
Latex Allergy
Seizures
STD
High Cholesterol
Concussion
Shortness of breath
Dizziness or Fainting
Low Blood Pressure
High Blood Pressure
None
Other
Please describe condition(s) if "other" was chosen:
Have you ever had any surgical procedures?
*
Yes
No
Please list previous surgeries:
*
Please list all medications and supplements that you are currently taking including amount and frequency:
*
Do you have any allergies?
*
Yes
No
Please list allergies:
Occupation & Lifestyle
If you are employed, please describe your current position:
*
How many hours do you spend in a seated position per day?
*
Please Select
0-2
2-4
4-6
6-8
8-10
10-12
12-14
14+
What is your current exercise program?
*
How many hours of sleep do you get each night?
*
Please Select
0-2
2-4
4-6
6-8
8-10
10+
Do you smoke?
*
Please Select
Yes
No, Never Have
No, Quit Previously
What do you consider your current level of stress to be?
*
None
Minimal
Moderate
High
Very High
What activities do you enjoy doing in your spare time?
Do you experience fatigue or lack of energy?
*
Yes
No
Have you experienced any unexplained weight-loss?
*
Yes
No
Do you experience night-sweats?
*
Yes
No
How would you describe your current physical fitness level?
Please Select
Poor
Fair
Average
Good
Excellent
How would you describe your current nutritional habits?
Please Select
Poor
Fair
Average
Good
Excellent
1.) CANCELLATIONS: Please make your best effort to cancel 24 hours prior to your scheduled appointment so other clients can be accommodated. 2.) LATE ARRIVALS: If you are more than 15 minutes late for your appointment, your appointment will be rescheduled due to inability to extend your appointment time into the next client's session. 3.) CORRECT INFORMATION: All the information on this form is correct and to the best of my knowledge. I have sought and followed any necessary medical advice. I understand that all the information given will be kept confidential. I AGREE TO THE ABOVE TERMS & CONDITIONS
*
Yes
No
Electronic Signature
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First Name
Last Name
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