National Pain Relief Institute
National Pain Relief Institute

"My first session was the single most effective thing EVER in giving me some understanding of what was wrong with my Low Back. I've now been pain-free for the longest period of time I can remember."
- Robert Todd, Musician

New Client Information

First Name Last Name
Date of Birth
Phone Mobile Fax
Address City State Zip Email
Occupation Gender Height inches  Weight lbs  Ideal Weight
Physician Name and Phone
Today's Date No. of Children     Age Age Age
Which therapist are you working with?
I'm interested in:  Personal Training    Pain Relief Therapy    Nutrition Coaching 
Whom may we thank for referring you?

History

Current health problems?
Current medications (prescription or over-the-counter)?
Current nutrition supplements?
Major Injuries, Surgeries, Hospitializations, Accidents and any Complications
Year Operation, Illness, Injury... Current Status
Corrective Lenses   Dentures   Hearing Aid   Medical Devices

Clearing

Are you recovering from a cold or flu?  Have you suffered an injury recently? 
Are you suffering from any contagious conditions, including skin conditions? 
Fever?  High Blood Pressure?  Heart Condition?  Hemophilia?  Vericose Veins?  Diabetes?
Aneurysm?  Osteoporosis?  Cancer?  Do you have any blot clots or a history of them?
Are you suffering from any inflamatory conditions? Have you had an unintentional weght gain or loss of 10lbs
or more in the last 3 months?
 Pregnant?   Recent Changes in: Sight?  Hearing?  Taste?  Smell?  Hot/Cold?  Movement?
What blood thinners, pain medications or anti-inflammatory medication are you taking?
Downs Syndrome?  Rheumatoid Condition?   Autoimmune Condition?
 Date of last physical exam?