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ARPwave South Carolina
ARPwave Strength Training Evaluation Form
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Indicates required field
Who Referred You?
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Name
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First
Last
Phone Number
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Phone Number (secondary)
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Email
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Date of Birth
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Gender
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School/Employment Status
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Your Physician's Name
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First
Last
Physician's Phone Number
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Please answer the following:
Are you Pregnant? Y/N
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Which activities bother you the most?
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Rate your Pain/Weakness on a 1-10 scale
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Are you being treated for Cancer? Y/N
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Please list ALL diagnostic tests performed by any Doctors including X-Ray, MRI, Lab Work, Functional Testing, Psychological Testing, Electrodiagnostics or others.
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When did your symptoms begin?
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Test Results (if any)
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Please list ALL treatments you have had including Rest/Ice/Compression, Physical Therapy, Medication, Surgery, Chiropractic, Massage, Alternative or others
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Are you using a Pacemaker or ICD? Y/N
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Are you on Medication or have a history of Blood Clots? Y/N
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Truthful Representation:
Upon selecting the following box stating "ALL INFORMATION IS TRUE" I hereby state that all the information I have provided is true, correct and complete. If more information about my condition becomes known, I will tell My Back and Body Clinic as soon as possible so that it can be added to my record:
ALL INFORMATION IS TRUE
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Yes
Describe your weakness/injury/symptoms
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Submit
Home
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ARPwave South Carolina