Confidential Medical Information Online Form

Full Name:	* required
Confidential Medical Information
State current problem(s):	* required
1 = NO PAIN and 10 = WORST PAIN    What has been your average pain over the past few days: 0 1 2 3 4 5 6 7 8 9 10
Are you currently being treated by:
Another Therapist
Chiropractor
Home Health Agency
Major surgeries that affect exercise:
Allergies:
List current medications:
Request information on:
Check if you currently have or previously had any of the following:
Arthritis	High Blood Pressure
Asthma	Gout
Cancer	Seizures
Circulation Problems	Stroke
Diabetes	Ulcers
Heart Problems	Other Illnesses
Please specify: