Intake Form 1
Please Fill This Out and Bring to Your Appointment

 Gloria Tucker MD                        MSK Intake 1

Diplomate of the American College of Sports Medicine              

 

Name_______________________________________   Date____________

What is your 1st problem? _________________________________________

Where exactly are you having pain/numbness?  ________________________

When did it begin? _________ Was there an injury ? ____________________

On a 1-10 scale how bad is your worst pain? _____  What brings on your worst

pain?____________________________________________ How bad is the pain

when you are feeling your best? ____  What helps the pain to quiet down? ______

__________________________________________________________________

What 3 things would you like to do that you are unable to do? 1) _______________

2) __________________________ 3) ____________________________________

What treatments have you tried from other professionals? ____________________

 

What treatments worked for you? ___________________________________________

Have you had x-rays or MRIs? ______ What did they show? ____________________

____________________________________ Please be sure to bring them in!

 

What is your 2nd Problem? _____________________________________________

Where exactly are you having pain/numbness?  ______________________ ___________________________________________________________________

When did it begin? _________ Was there an injury? ________________________

On a 1-10 scale how bad is your worst pain? _________ What brings on your worst 

pain? ____________________ How bad is the pain when you are feeling your

best? ______ What do you do to bring the pain level down? ____________________

What 3 things would you like to do that you are unable to do now? 1) __________

2) _________________________ 3) _________________________________

What treatments have you tried from other professionals? _____________

 

What treatments worked for you? ___________________________________

Have you had x-rays or MRIs? ______ What did they show?_______________ __________________________________ Please be sure to bring them in!

 

What is your 3rd problem?__________________________________________

Where exactly are you having pain/numbness?  ________________________

_______________________________________________________________

What 3 things would you like to do that you are unable to do now? 1) __________

2) ____________________________ 3)_______________________________

When did this pain begin? _________ What brought it on? ___________________

On a scale of 1-10, how bad is your worst pain? ______ What brings on your worst

pain?  ______________________ How bad is the pain when you are feeling your best?

___________ What do you do to your pain level down? ______________________

What treatments have you tried from other professionals? ____________ ________

________________________________________________________

Have you had x-rays or MRIs?______ What did they show? _________________  _____________________________________Please be sure to bring them in!

 

 Have you ever had Prolotherapy/ PRP / Neuro Prolo/ Ozone Therapy? (CIRCLE)

For What Conditions? ___________________________________________

______________________________________________________________

Result?_______________________________________________________

_____________________________________________________________

 Are you currently on any blood thinners?_____________________________

Has anyone ever had difficulty drawing your blood? ______________________

Do you have any allergy to corn?_________or ‘cain anesthetics? Ie Lidocaine/Procaine? ______________________________________________.

 

______________________________________                ____________

Signature                                                                             Date

 

We look forward to meeting you and sincerely hope that we can help you!

 

 

 

 

 

 

 

 

 

© 2017 Dr. Tucker Prolotherapy and Gloria Tucker, M.D. All Rights Reserved.