Please answer below for: What is your chief concern and reason for this visit?
Do you currently experience any of the following symptoms?
Please number your top chief complaints 1-4
Recent is in the last 6 months, Chronic is longer than 6 months
What is your level of head, neck or facial pain: 0 = no pain to 10 = worst possible pain
What are the results you are seeking from treatment?
Sleep Conditions - Please select the yes or no answers based on your average sleep experience and/or what a sleep partner has told you
Please check any and all medications or substance that have caused an allergic reaction
Please list all medications & supplements (over-the-counter & prescription) you are taking and the reason you take them OR
Provide a copy of your personal Medication List
Previous Treatment, Medications and Other Therapies Attempted For The Condition We Are Evaluating
Health And Medical History
Have you sustained injury to:
Surgical History-Have you had any of the following:
Medical History – Patient and Family
Do you have or have experienced any of the following?
Additional Symptoms – HEAD PAIN Please complete for all that apply:
For the below categories, please indicate L or R where applicable
For the below categories, please respond with Yes or No ….DO NOT LEAVE BLANK
Please fully complete both sections 1. and 2. below
1. DAYTIME SLEEPINESS EVLAUATION - EPWORTH SLEEPINESS SCALE
For the following situations, answer with one of the following numbers:
0 - would never doze 1 - slight chance of dozing 2 - moderate chance of dozing 3 - high chance of dozing
2. NIGHTTIME SLEEPINESS EVALUATION
The California Consumer Privacy Act (CCPA), effective January 1, 2020 creates new consumer rights relating to the access to, deletion of, and sharing of personal information that is collected by businesses.
You can learn more about California’s CCPA by reviewing this state sponsored CCPA link: https://oag.ca.gov/privacy/ccpa; or, by following additional information via this BBB link: https://betterbusiness.blubrry.com/2020/02/05/ccpa-is-here-what-does-it-mean-for-businesses/; or, by contacting your legal counsel.
I authorize the release of all examination findings and diagnosis, report and treatment plans, etc., to any referring
or treating health care provider. I additionally authorize the release of any medical information to insurance
companies, third party billing companies, or for legal documentation to process claims. I understand that I am
responsible for all charges incurred for my treatment regardless of insurance coverage.