PATIENT PRE-REGISTRATION Please fill out the form below and submit for pre-registration. First Name(required) Middle Name Last Name(required) Email(required) Phone Date of Birth – MM/DD/YYYY(required) Gender(required) Race / Ethnicity Height(required) Weight(required) Check All That Apply Currently Under A Doctors Care Do you consider yourself healthy? Acid Reflux Afternoon Headaches Anxiety Attention Difficulties Asthma Bleeding Disorder “Brain Fog” or “Mental Clouding” Cardiovascular Problem(s) Chest Pain or Discomfort Chronic Pain Concussion Constipation Consume Alcohol Depression Diabetes Diarrhea Difficulty Controlling Blood Glucose Difficulty Controlling Blood Pressure Difficulty Standing Still Dizziness Upon Standing Ear / Sinus Problem(s) E.D.S. (Ehlers-Danlos Syndrome) Estrogen Imbalance Evening Edema Excercise Intolerance Excessive Sweating Exhaustion Fainting Fatigue Gastro-Intestinal Problem(s) Headaches Heartburn Heart Disease Check All That Apply Heart Palpitations Heat Intolerance “Hot Flashes” Kidney Disease Learning Disorder(s) Light-Headedness Little or No Energy Memory Difficulties Menstruating Menopause / Perimenopause Migraine Headaches Muscular Problem(s) Nausea “Night Sweats” Occasional Light-Headedness Other Psychological / Psychiatric Diagnosis Persistently Cold Hands or Feet P.O.T.S. (Postural Orthostatic Tachycardia Syndrome) Restless Legs Sex Dyfunction Shortness of Breath Sleep Difficulties Seizure Disorder(s) Sickle Cell Skeletal Problem(s) Sleep Disorder(s) Smoker Stroke Thyroid Dysfunction Traumatic Injury Trouble Falling Asleep Unexplained Arrhythmia Unexplained Seizure Upset Stomach Varicose / Spider Veins Surgery – Please Describe Allergies – Please Describe Additional Conditon / Diagnosis / Issue – Please Describe Excercise – Please Describe Activity & Frequency Sleep – Please Describe Sleep Habits & Patterns Additional Info About Lifestyle / Health / Concerns Submit Physio PS © 2020 All Rights Reserved. The material and information provided by Physio PS is for general information purposes only. You should not rely upon this material or information for basis of making healthcare, treatment or diagnosis decisions. While Physio PS strives to provide the most correct and up to date information and data, Physio PS makes no representations or warranties of any kind, expressed or implied about the completeness, accuracy, reliability, suitability or availability with respect to the information, products, services or related graphics contained. Any reliance placed on such material is therefore strictly at your own risk. Reporting Information is supplied under license by NCRC LLC.* ‘RFa’ is known to be a measure of Parasympathetic activity and ‘LFa’ is known to be a measure of Sympathetic activity, based on reference: Colombo J, Arora RR, DePace NL, Vinik AI, Clinical Autonomic Dysfunction: Measurement, Indications, Therapies, and Outcomes. Springer Science + Business Media, New York, NY; 2014.
