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Have you reviewed Check-In information?
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Provider Summary of Intake (Required)
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ISSUES WITH ANY OF THE ITEMS BELOW? *REQUIRED*
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If 'YES', answer each question below.
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Balance or Coordination?
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If 'YES", explain:
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Bowel or Bladder Dysfunction?
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If 'YES", explain:
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Fever or Chills?
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If 'YES", explain:
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Night Sweats or Weight Changes?
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If 'YES", explain:
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Is the abdomen distended w/ abnormal bowel sounds?
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If 'YES", explain:
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Abdominal tenderness or hepatosplenomegaly?
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If 'YES", explain:
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Joint Swelling or Redness?
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If 'YES", explain:
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Pain Radiating into Upper Extremity(UE)?
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If 'YES", explain:
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UE Numbness/Tingling/Paresthesia/Weakness?
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If 'YES", explain:
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Pain Radiating into Lower Extremity(LE)?
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If 'YES", explain:
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LE Numbness/Tingling/Paresthesia/Weakness?
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If 'YES", explain:
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History/Exam Reviewed? (*DC Only)
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Additional Information
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