SA Pain Relief

Equiscope Therapy

HIPAA COMPLIANT

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Patient Intake Forms

Complete all sections below. Your information is encrypted and handled in accordance with HIPAA privacy standards.

Step 1 of 6

Personal Info & Health History

Personal Information

Please provide your contact and personal details.

Full Name *

Date

Age

Date of Birth *

Gender

MaleFemaleOther

Occupation

Street Address *

State

Zip Code

Cell Phone *

Home Phone

Work Phone

Email *

Relationship Status

SingleMarriedPartneredWidowedDivorced

How did you hear about us?

What is your main concern today? *

Health History

This information helps us provide safe and effective therapy.

Under care of physician in the past year?

YesNo

Diagnosed with chronic illness?

YesNo

Do you exercise?

YesNo

Recent injuries?

YesNo

Prior or recent surgeries and dates

Metal or electrical implants?

YesNo

Demand pacemaker?

YesNo

Botox injections?

YesNo

Known allergies?

YesNo

Allergies to latex or drugs?

YesNo

Problems sleeping?

YesNo

Pregnant or breastfeeding?

YesNoN/A

Epileptic or seizures?

YesNo

Stroke or hypertension?

YesNo

Smoke tobacco?

YesNo

Daily Consumption

Water

Coffee

Tea

Alcohol

Soda

Skin conditions (eczema, psoriasis, rashes, etc.)

Prescription or over-the-counter medications

Supplements (vitamins, herbs, etc.)

Do you take minerals or electrolytes?

YesNo

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SA Pain Relief

Equiscope Therapy

Stop managing pain. Start healing it. Non-invasive, drug-free Electro-Equiscope therapy in the Texas Hill Country.

Contact

830.252.1131 [email protected]

Canyon Lake, TX | By Appointment

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