Trio Therapy
TRIO THERAPY Intake Form
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Personal Info
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Virgin Islands, U.S.
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Province / State
Postal / Zip Code
Emergency Contact
Emergency Contact
Emergency Phone
Relationship
Other
Medical Info
Primary Complaint
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General Health
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Current Treatment
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Past Treatment (from other practitioners)
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Medications
Injuries
Surgeries
Additional Info
Conditions
Well Being
Exercise
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Flexibility
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Range of Motion
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Treatment Goals
Health Advice for Healing
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Pain Relief
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Rehabilitation
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Stress Relief
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Support in Healing/Recovery
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Other
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Area of Complaint
Neck
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Left Side of Neck
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Right Side of Neck
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Upper Back
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Left Side of Upper Back
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Right Side of Upper Back
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Mid Back
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Left Side of Mid Back
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Right Side of Mid Back
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Low Back
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Left Side of Low Back
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Right Side of Low Back
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Chest
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Abdomen
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Left Arm
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Right Arm
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Left Shoulder
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Right Shoulder
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Left Elbow
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Right Elbow
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Left Wrist
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Right Wrist
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Left Hand
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Right Hand
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Left Leg
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Left Thigh
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Left Calf
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Right Leg
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Right Thigh
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Right Calf
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Left Gluteal
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Right Gluteal
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Left Hip
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Right Hip
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Left Groin
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Right Groin
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Left Knee
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Right Knee
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Left Ankle
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Right Ankle
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Left Foot
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Right Foot
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Sacrum
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Tailbone (coccyx)
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Headaches
Chronic Daily Headache
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Cluster
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Headaches
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Migraines
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Sinus
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Tension
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Other Headaches
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Skin
Skin Conditions
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Bruise Easily
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Eczema
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Hypersensitive Reactions
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Psoriasis
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Sensitive Skin
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Musculoskeletal
Broken Bone / Fracture
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Plantar Fasciitis
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Carpal Tunnel Syndrome
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Spasms / Cramps
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Chronic Myofascial Pain Syndrome
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Strain/Sprain
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Fibromyalgia
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Fracture
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Jaw Pain (TMJD)
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Joint Injury
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Arthritis
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Joint Stiffness / Swelling
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Other Musculoskeletal
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Accident Info
Date of Injury
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Which best describes what you are experiencing
Pain
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Mild
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Getting Worse
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Ache
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Moderate
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Staying the Same
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Tension
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Getting Better
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Discomfort
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Constant
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Imbalance
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Intermittent
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Increases with Activity
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Decreases with Activity
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No Change
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Other
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Allergy
Environmental
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Latex
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Medical
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