Testadmin2023-06-05T06:19:49+00:00 First: Last: Hand Dominance: RightLeft Height: Weight: Hand Dominance: Who referred you to our clinic?: Do you see any other medical specialists (i.e., cardiologist, etc.)? If yes, please list: Pharmacy name and address: Date of injury: How did the injury occur: Where did the injury occur: Injury result of: SportsAuto accident*On the Job If on the job, is it Workers' Comp? : YesNo Signature: Injury Location: RightLeft ShoulderElbowHandHipKneeFoot Next ArmWristFingerLegAnkleToe What symptoms are you experiencing? : LockingGrindingCatchingWeaknessPoppingNumbnessStiffnessOther Pain Level (0-10; 10 being severe pain) : BackNext Have you ever had Physical Therapy for this issue? : YesNo What increases your pain? : Have you had chiropractic treatment? : YesNo Back