CONFIDENTIAL CASE HISTORY FOR TRIANGLE TRIGGER-POINT THERAPY

Confidential Patient
Case History Form

Contra-indications for receiving neuromuscular therapy may be acute trauma, broken bones, illnesses, severe colds or infections, active cases of shingles, GBS, epilepsy, etc. If any of the above apply let us know.

Contact Information

First Name

Last Name

Today's Date

Home Phone

Work Phone

Mobile Phone

From the above contact information, which is the quickest way to reach you during the day?

After 5:00PM?

Where would you like reminder calls?

Who may we thank for referring you?

If you did not come from a referral, how did you hear about us?

Will you need CPT coded receipts?
YesNo

Street Address

Street Address 2

City

State

Zip Code

Occupation

Place of Employment

Personal Information

Date of Birth

Age

Marital Status
SingleMarriedDivorced

Spouse's Name

Spouse's Contact Information

Name(s)/Age(s) of Children

Medical Information

Height

Weight

Blood Type

Are you allergic to laytex?
YesNo

Any other allergies?

Who Is Your Primary Care Physician?

Surgeon

P.T

OBGYN

Dentist

Chiropractor

Acupuncturist

Other Providers?

Please describe in detail why you are here? Using words like burning, radiating, stabbing, aching, throbbing, numb, tingly, itchy, shooting, restless, cramping, etc., and where it is located?

Have you seen any of the above health care providers for this condition and if so who?

What did they say about it?

Were there any diagnostic tests performed and what was found?

How long has this pain been bothering you?

Is this the first time you have had it?

If not, when was the first time?

On a scale of 1 to 10, with 10 being the most painful, how painful is today?

What do you think caused it it?

Are there any other areas of your body that hurt or give you trouble and if yes, please describe?

If the pain you are here for today is not present at all times, is there anything that you do which will quickly bring it on, or make it worse? Please describe.

Does the pain interrupt your sleep?
YesNo

If so, how often?

What have you tried prior to coming here to get relief from any of the aches and pains that you have listed so far? Check all that apply:

Over The Counter MedicationsPrescription MedicationsWeight LossStretchingCardio Vascular ExerciseWeight LiftingChiropracticMassage or BodyworkChanging Pillows or MattressHeel Lifts or Shoe BuildsBack Supports Or Leg BracesElectric DevicesMedication InjectionsYoga, Pilates, Etc.AcupunctureOsteopathic TreatmentsTaking Time Off Work/RestingSleepingTaking A Walk / Moving AroundTaking A Hot ShowerTaking A Hot Bath Or Hot TubIce Packs Or Ice DipsHeating PadsA New Chair, Couch, Car, Etc.Arch Supports/Shoe Lift/ Etc.Surgery, Lasers, Etc.Topical Creams or GelsPhysical TherapyCrying, Screaming, PrayingMouth Guard/Splint/Braces

Anything not listed here?

Of these, what has been the most helpful?

Is there anything that you have had to give up because of the pain you are here for that you would like to resume doing in the future?

Do you have other fitness goals we can assist you with once pain is better?

When was your last complete physical with blood work?

Have you ever had a stress test/cardio-vascular fitness test?
YesNo

When?

Lung/Chest X-Ray?
YesNo

When?

Spinal X-Ray?
YesNo

When?

MRI?
YesNo

When?

CAT Scan?
YesNo

When?

Arthrogram?
YesNo

When?

Other?
YesNo

Do you ave high or low blood pressure?

Arthritis?
YesNo

Fibromyalgia?
YesNo

Other diagnosed health conditions? Please list.

Even if you do not think it was a big deal, have you ever been in an impact accident such as car, boat, motorcycle, etc? And if yes, how many times, how old were you and how fast were you (and the other object if you hit something else) going?

Have you ever had a bad fall or sporting injury that caused soreness/pain for more than 2 days, visible bruising, concussion, etc. (i.e. from a crib, off a bed, a porch, out of a tree, off a house, off a bike, a skateboard, on ice, etc.) and how many and how old were you?

In any of the above accidents, what was injured?

Have you ever broken any bones, sprained, strained or torn a muscle, tendon or ligament? And if so, how old you were you and describe what happened.

Did you have residual or recurring pain in any of these areas days, weeks or months afterward or as the years passed? Please describe.

Have you ever had a surgical procedure? Necessary or cosmetic. List the year, your age, what was done.

Complications?

Has anyone ever told you that you have a leg length difference?
YesNo

By Whom?

When?

Short R or L and by how much?
Were x-rays of your pelvis and legs taken to determine this?
YesNo
If not, how was it measured?

Do you currently have a full build on the short leg side, wear inserts, arch supports, orthotics or heel lifts?
YesNo
How often do you use them?

Do they help?
YesNo
In what ways?

Have you ever been told that you have curvature of the spine or scoliosis?
YesNo
How old were you when you were first told this?

Do you wear braces on your teeth?
YesNo
If so, when did you get them, and how much longer do you wear them?

If you said no, have you ever worn braces on your teeth?
YesNo
Do wear a night guard or bite splint?
YesNo
Were there any birth traumas when you were born such as a C-section or forceps delivery?
YesNo
Any other issues, deformity or complications that you know of?

Have you ever worn leg braces?
YesNo
What you ever worn corrective shoes?
YesNo
Have you ever given birth?
YesNo
How many times?

Type of delivery?

Were there any complications?

Did you receive any massage therapy before, during or after pregnancy? Describe.
YesNo
Describe?

Does anyone in your biological family suffer from any of the same aches, pains or health issues that you do?
YesNo
Who and what?

Are there any highly stressful emotional events currently in your life such as marriage, divorce, a loss through separation or death, difficult relationships, relocation, new job, prolonged depression, unhappiness, you just won the lottery etc. (The nervous system does not differentiate where over stimulation comes from, it simply monitors the sum total)
YesNo
Have there been any of these types of stimulants over the past 2 years?
YesNo
If yes, are you currently working on reducing this stress?
YesNo
Are you under the care of a psychiatrist/psychologist or another licensed professional for the effects?
YesNo
May we contact your current health care practitioners in order to get further information, copies of x-ray reports, MRI results, etc., if we deem it necessary while working with you?
YesNo
If no, what is your objection based on?

Lifestyle

Describe the type of work you do and any daily activities that occur repetitively for hours at a time (i.e. sitting, driving, standing, bending, lifting, typing, reading, cradling phones, holding a baby, sewing, etc.)

Do you stretch your entire body 3 or more times a week for at least 20-30 minutes at a time (lengthen, not strengthen)?
YesNo

Or do you stretch parts of your body every now and then, before or after exercise for 2-10 minutes at a time?
YesNo

If you stretch just parts, what parts do you tend to focus on?

Do you lift weights or engage in resistance workouts 2 or more times a week?
YesNo

Do you do cardio vascular exercise (speed walking, running, jogging, biking, hiking, swimming or other wise get your heart rate up for at least 20-30 minutes at a time) 2 or more times a week?
YesNo

Do you do other types of activities such as yard work, basketball, softball, golf, hockey, soccer, or any other kind of sporting activity 2 or more times a week?
YesNo

Are you a “weekend warrior” who does not stretch or exercise regularly but will have blasts of movement or activity on a weekend, once a month or a few times a year?
YesNo

Or are you a total couch potato who could care less about stretching and exercise?
YesNo

Please rate your strength on a scale from 1 to 10, with 10 being the strongest.

How would you rate your flexibility on a scale from 1 to 10, with 10 being very flexible.

How would you rate your cardiovascular endurance on a scale from 1 to 10, with 10 being very high endurance.

Do you have any scars or adhesions from previous injuries or surgeries and if so, where?

Do you have spider or varicose veins anywhere?

If yes, how old were you when you first noticed them?

How many glasses (16-20 oz) of plain water do you drink daily?

Would you say that you have a well balanced diet of fruits, veggies, protein, carbs, healthy fats, etc., each day?
YesNo

Are you a Vegetarian or Meat Eater?
VegetarianMeat EaterVegan

If you eat meat, which meats do you eat? Choose all the apply.
ChickenFishPorkVenisonBeefOther

Do you have processed sugar in your diet on a daily basis?
YesNo

Do you have caffeine on a daily basis and if yes, how much?

Servings of alcohol per-week?

Do you use artificial sweeteners?
YesNo

Do you smoke?
YesNo

Do you chew tobacco?
YesNo

Do you have other dietary or recreational habits considered to be unhealthy?
YesNo

List all medications (both prescription and over the counter) currently taken and the frequency and dosage of each

List all daily vitamins, minerals or herbal supplements.

We will make every effort to assist you out of pain by educating you about your body, wellness techniques, preventive care, and other things on the market for pain relief while you are at this clinic. And because of this approach, it is important for us to know where you stand before we make any suggestions or referrals to you based on our impressions. Regarding your history, daily habits, diet, activities, and even your current health care providers how open are you to making changes if what you are currently choosing does not appear to be producing the desired results?
Wide OpenSomewhat OpenNot Very OpenWill Need More Information

Thank you. Please agree below indicating your consent to receive our hands-on assistance with neuromuscular therapy, myofascial release, AIS and other associated therapies and information.
I AgreeI DisagreeWill Need More Information

Confidential Patient Case History Form

Confidential Patient
Case History Form