Sports / Dance injuries intake form 05/21

What physical activity do you participate in? Please specify your athletic level (amateur, semi-pro, or pro) and how many hours a week you practice.

Running

Swimming

Waterpolo

Biking

Triathlon / Duathlon / Pentatlon/ Marathon

Tennis

Golf

Lacrosse

Rugby

Hockey (Grass/Ice)

Volleyball

Handball

Basketball

Weight lifting

Other aerobic activity

Yoga

Martial arts

Pilates

Barre

Dance: Ballet

Dance: Modern

Dance: Other

Dance: Pole / Aero / Ring

Acrobatics / Calisthenics

Parkour

Athletics (Specify discipline)

Skating

Other

Are you a musician? If yes, please specify the instrument you play.

What brings you in today?

Characters: 0/255

Do you know the approximate date of your injury?

Have you taken any MEDICATIONS for treating this injury? Please comment on which medications, dose, and if it helped.

Anti-inflammatory non-steroidal (Alive, Ibuprofen, etc.)

Analgesic (Tylenol, Acetaminophen, Paracetamol, etc.)

Steroids

Muscle relaxers (Baclofen, Diazepam, Lorazepam, Restoril, etc.)

Other medications (please specify)

What PHYSICAL treatments have you taken for this injury so far? (please comment if it helped fully, partially, or none)

Physical therapy

Chiropractics

Acupuncture and other alternative medicines

Other treatments

None

How did the injury happened? (Please specify the injury mechanism, consequences and immediate treatment)

Are you seeing any physician in regard of this injury? (Please tell us more and send us their visit summary)

Have you done any IMAGING related to your current injury? (Please tell us which one and send us the report)

Which activities are affected by your condition?

Sitting down

Standing up

Sleeping

Standing for longer than...

Walking or running for more than...

Going upstairs

Going Downstairs

Standing up straight

Lifting arms up overhead

Lifting arms up to the side

Driving for more than...

Getting in or out of the car

Lifting weight heavier than...

Focusing on my work or tasks

Rises stress levels, anxiety, or depression

Other symptoms

Are you treated with any other medications not related to your current injury?

Claw Toe

Mallet Toe

Plantar Fasciitis

Plantar Wart

Corns/Callouses

Onychauxis

Previous Amputations

Dry/Cracked Skin

Onychocryptosis (Ingrown Nail)

Thickened Nails

Hallux Valgus

Onychomycosis (Nail Fungus)

Yellow Nails

Hammer Toe

Onychoptosis (Nail Loss)

Heel Fissures

Overlapping Toes

Involuted Nails (Curved/Pinched)

Pes Cavus (High Arch)

Bunions

Itchy or Peeling Skin

Pes Planus (Flat Feet)

Constipation

Gastroparesis

Ulcerative Colitis

Crohn's Disease

Hiatal Hernia

Diarrhea

Intestinal Gas/Bloating

Digestive Conditions

Intestinal Polyps

Abdominal Hernia

Diverticulitis

Irritable Bowel Syndrome

Acid Reflux

Eating Disorder

Poor Appetite

Adaptive Aids

Esophageal Disorder

Stomach Disorder

Celiac Disease

Fecal Impaction

Stomach Disorders

Other Gastrointestinal

Twitching of Face

Dural Ectasia

Numbness

Sleeping Disorders

Carpal Tunnel

Vertebral and Spinal Cord Injury

Epilepsy

Parkinsons

Stabbing

Cerebral Palsy

Fatigue

Peripheral Neuropathy

Stroke

Cerebral Vascular Accident (Stroke)

Fibromyalgia

Post Polio Syndrome

Syringomyelia

Cerebral-vascular Accident

Herniated Disc

Sciatic Pain

Bell's Palsy

Tethered Cord

Cerebrospinal Fluid Leak

Chiari Malformation

Huntington Disease

Seizure Disorder

Brain Disorder

Tingling

Chronic Pain Disorder

Loss of Sensation

Shingles

Brain Injury

Transient Ischemic Attacks (TIA)

Dizziness

Multiple Sclerosis

Shingles / Herpes

Burning

Other Neurological

Heart Condition/disease

Atherosclerosis

Blood Clots

Varicose Veins

Cold Feet

Cold Hands

Peripheral Vascular Disease

High/Low Blood Pressure

Phlebitis

Hyperlipidemia (High Cholesterol/Triglicerides)

Postural Orthostatic Tachycardia Syndrome

Raynaud Disease

Lymphedema

Stroke (CVA/TIA)

Chest Pain

Fainting Spells

Pacemaker

Other Cardiovascular

Recti Diastasis

Carpal Tunnel Syndrome

Tendonitis/Bursitis

Fibromyalgia

Myasthenia Gravis

Osgood-Schlatter Disease

Ankylosing Spondylitis

Scleroderma

Chronic Fatigue Syndrome

Torticollis

Fracture

Arthritis

Osteoarthritis

Osteoporosis

Scoliosis/Kyphosis

Chronic Myofascial Pain Syndrome

Whiplash

Gout

Osteomalacia

Artificial Joints / Special Equipment

Compartment Syndrome

Hereditary/Congenital Deformity

Baker's Cyst

Spasms / Cramps

Degenerative Disk Disease

Jaw Pain (TMJD)

Paget Disease

Bone Disease

Spondylolisthesis

Joint Dislocation (which one?)

Plantar Fasciitis

Strain/Sprain (What joint?)

Joint Stiffness / Swelling

Adhesive Capsulitis

Psoriatic Arthritis

Ehlers-Danlos Syndrome (Please specify what type)

Muscular Dystrophy

Other Musculoskeletal

Have you done any IMAGING related to your current injury? (Please tell us which one and send us the report)

Are you seeing any physician in regard of this injury? (Please tell us more and send us their visit summary)

Non-Surgical Scars

Skin Irritations

Acne

Eczema

Pigmentary Disorder

Surgical Scars

Allergic Dermatosis

Herpes

Plantar's Wart

Urticaria

Athlete's Foot

Hypersensitive Reaction

Psoriasis

UV Burn

Athletes Foot

Hypersensitive Reactions

Rash

Bruise Easily

Infectious Skin Conditions

Melanoma

Rosacea

Chemical Burn

Melanoma/Carcinoma

Severe Irritability

Cosmetic Surgery

Moles

Skin Conditions

Dermatographia

Allergic to Iodine

Dry Skin

Oily Skin

Mature Skin

Sensitive Skin

Sun Damage

Using ALPHA Hydroxy Acids

Using RETIN A

Other Skin

Emphysema

Infectious Respiratory Conditions

Respiratory Conditions

Asthma

Respiratory Tract Infection

Bronchitis

Shortness of Breath

Chronic Cough

Sinus Problem

COPD

Tuberculosis

Cystic Fibrosis

Other Respiratory

Hyper/Hypothyroidism

Pituitary and Growth Disorder

Prostate Condition

Acute Pancreatitis

Temiskaming Diabetes Program

Adrenal Fatigue

Diabetes (Please specify type)

Other Endocrine

Bleeding Disorder

Hypercoagulability

Blood Thinner Medication

Polycythemia

Fainting Spells

Haemophilia

Thrombosis/Embolism

Hepatitis

Anemia

HIV/AIDS

Other Blood disorders

Cardiovascular

Diabetes

Respiratory

Arthritis

Cancer

Genetics

Mental or emotional conditions

No restrictions

Vegan

Vegetarian (do you consume diary products? eggs?)

Pescetarian

Paleo

No carbs

Gluten-free

Environmental

Food

Latex

MCAS/Mastocytosis

Other allergies not mentioned above

Any other condition not mentioned above?

Would you like us to know anything else in regards of your current condition, expectations of treatment, or any other information?

Sports / Dance injuries intake form 05/21

This section relates ONLY to your sports injury

Your general health and lifestyle