Thank you for taking the time to complete these forms.
If you have any questions don't hesitate to call Raj at 310-930-5884 or email me at
raj@painprof.com
Painless Trigger Point Therapy intake form
Firstname:
*
Lastname:
*
Consultation Type:
*
choose one
Online
in Person
Cell:
Email:
Website:
Address:
City:
State:
Zip:
Birthdate:
Profession:
Sex:
M
F
Current Sport/Exercise
:*
Previous Sport/Exercise
:*
Attention Area/s:
*
Recent Injury
Old Injury:
How long ago:
*
1 - 11 months
1 - 5 years
6 - 10 years
10 - 20 years
History of your condition in as much detail as you like:
Describe in detail how you feel now, and the areas that need attention... ... and then Describe the development of your condition from the beginning, no matter how long ago...
Previous Treatments and Results:
Your Short-term and Ultimate Goals
Hand Strength:
average
strong
weak
have pain
stiff
Trigger Point Knowledge:
no knowledge of
good knowledge
some knowledge
own T.P. Workbook