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Intake Form for Elite Laser Therapy

Please, take your time filling out this form. It is imperative that we have accurate information to be able to complete a thorough assessment and help us purse the best course of action.

Date:

First Name:

Last Name:

Address:

City/State:

Sex:

Zip Code:

Home Phone:

Work Phone:

Mobile:

Email:

Birth Date:

Age:

How did you hear about us?

Please tell me where you feel your current pain/symproms?

Did your pain come on suddenly or gradually?

Was there an injury, illness, or condition?

How often are you experiencing symptoms?

Constantly (76-100% of the day)

Occasionally (26-50% of the day)

Frequently (51-75% of the day)

Intermittently (0-25% of the day)

Are your symptoms:

Same

Gradually getting worse

Rapidly getting worse

Describe your pain: (Numbness, Pins & Needles, Burning, Aching, Stabbing)

Have you received any treatment for this problem in the past?

If so, what treatment and did it help?

Whom have you seen for your symptoms?

No One

M.D.

Chiropractor (D.C.)

P.T.

Other

What treatments did you receive?

Diagnostic testing?

X-rays

CT scan

MRI

Other

If so list diagnosis and dates:

Check if experiencing conditions

Arthritis

Back pain/Sciatica

Plantar Fascitis

Carpal Tunnel Syndrome

Bursitis

Rotator Cuff Strains and Tears

Tennis Elbow

Golfers Elbow

Stress Fractures

Vascular Disorders (Systemic)

TMJ Disorder

Migranine/Headaches

Neck pain or spasms

Shin Splints

Fibromyalgia

Hand or wrist pain

Bunions

Hip Discomfort

Legament Tears

Numbness

Joint Sprains

Bulging, Hernated Discs

Sports Injuries (Muscle Strains)

Post Surgical Recovery

Nerve Conditions

Inflammatory conditions, joint, muscle, vascular...

Sinus trouble

Knee ligament injuries

Tendonitis

Peripheral Neuropathy

Diabetic Neuropathy

Other injury, illness or conditions?

PLEASE ANSWER THE FOLLOWING QUESTION:

Are you Pregnant?

Yes

No

Do you have a pacemaker or any other medical transplant equipment?

Yes

No

Do you suffer from Encephalopathy?

Yes

No

Are you hypersensitive to powerful light energy?

Yes

No

Do you have any dermatological conditions? If so, what type?

Do you have cancer or tumor? If so, what type?

Are you taking any performance-enhancing drugs?

Yes

No

Are you using corticosteroids or any other steroid therapy?

Yes

No

Please list any medications, drugs, or herbs that you are taking:

I have answered the above questions to the best of my ability. I understand that this information will only be used to help provide me with the most accurate and best care.

Thank you for taking the time for filling out this form accurately and completely. We truly value your health and this form will help guide us in assessing your personal treatment plan.

Keitzke Plaza

4600 Keitzke Ln.

Building O #267

*Off Keitzke Ln. turn into Keitzke Plaza

at the sign

*Drive straight to building O on the Left side

*Take sidewalk towards the end-located

on the left side

Contact Us

Thanks for submitting!

Click to Schedule a Consultation

Email:

info@EliteLaserTherapy.com

Phone:

775-722-0884

FDA Cleared Medical Laser Therapy does not require the use of drugs or surgery, and there are NO dangerous side effects or risks. In addition, Laser Therapy provides enhanced treatment outcomes faster than any other treatment modality.

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