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Sports / Dance injuries intake form 05/21

Personal Info
Contact Info
Emergency Contact
Doctor

 

This section relates ONLY to your sports injury

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.

Other
Conditions

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

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

No painThe worst pain

Which activities are affected by your condition?

Your general health and lifestyle

Surgeries

 

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

Medications
Conditions
Feet
Gastrointestinal
Neurological
Cardiovascular
Musculoskeletal
Skin
Respiratory
Endocrine
Blood
Family History
Eating Habits
Allergy
Other