PATIENT PRE-REGISTRATION Please Complete the form below. We will email you upon completion. First Name(required) Middle Name Last Name(required) Email(required) Phone Date of Birth – MM/DD/YYYY(required) Please Describe Any Symptoms or Ailments Surgery – Please Describe Allergies – Please Describe Additional Condition / Diagnosis / Issue – Please Describe Exercise – 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.