Please select which location you are submitting this form to:

First Name: *

Last Name: *

Age: *

What is your occupation? *

Which is your dominant hand? *

What activities do you like to do? *

How Did You Hear About Us? *

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Tell us about your injury

How long have you had this injury? *

Date of Injury: *

How did this injury occur? *

Any significant immediate pain or swelling/stiffness following the injury?

Is the pain constant or intermittent? *

Do you experience any of the following as a result of the injury? *

Movement Symptoms:

Weight bearing ability: *

On a scale of 0 - 10 how would you score your pain on average (0 is no pain, 10 is the worst pain)? *

Have you experienced a disruption of your sleep? *

If Yes, how often are you awoken?

Do you experience pain or stiffness in first thing in the morning? *

As you use the body part does it get worse? *

What aggravates your symptoms? *

What eases your symptoms? *

The following pertains to the activities you are having the most difficulty with (eg. - sitting, walking, reaching, etc.).

Please state the activity and score (on a scale of 0 - 10) your ability on average:

(0 = No Difficulty and 10 = Unable to Perform)

Activity 1:

Difficulty:

Activity 2:

Difficulty:

Activity 3:

Difficulty:

What are your goals/expectations from your experience with us? *

Conditions/Symptoms

Do you experience any of the following?

 YesNoPastComments
Dizziness *
Balance Problems *
Change in bladder and bowel function *
Numbness in face *
Numbness in the groin region *
Pain with coughing or sneezing *

If you have had any investigative tests done for this injury (such as X-ray, MRI, etc.), then please provide a description:

Are you currently taking any medications?

Past Medical History (Information will remain confidential):

Please list any other conditions you have (separating each condition with a comma):

Have you had any other injuries, relevant surgeries or trauma in the past? If so please list:

Year:

Injury: