Name
*
First Name
Last Name
Date of birth
*
Gender
*
Home address
*
Zip code
*
Email
*
Phone
*
(###)
###
####
I give permission for voicemails left on this number regarding my care
*
Yes, voicemails may be left for me
Yes, voicemails and text messages may be left for me
No, please do not leave any message but email is fine
Occupation
Emergency contact's name
*
First Name
Last Name
Relationship to emergency contact
Spouse/Partner
Parent
Friend/Colleague
Other Family Member
Emergency contact's phone
*
(###)
###
####
Number of children
0
1
2
3
4
5
How did you hear about our clinic?
*
Why are you seeking care at Shine?
*
How did your symptoms begin?
*
When did you begin experiencing symptoms?
*
What makes your symptoms better?
*
What makes your symptoms worse?
*
Average pain level
*
mild (0-3 out of 10)
moderate (4-7 out of 10)
severe (8-10 out of 10)
How often do your experience your symptom(s)?
*
Infrequently (0-2 days per week)
Often (3-5 days per week)
Constantly (every day)
What treatments have you tried for your symptoms?
*
What have been the major obstacles to your recovery?
*
Any other symptoms?
If you've had any imaging (MRI, x-ray, etc) for your symptoms, what were the findings?
*
Please list all past surgeries, major injuries, auto accidents, trauma and related events (ie live births). Please indicate approximate date(s)
*
Please list any medical device(s) implanted in your body
Other medical conditions?
*
Do you use any of the following?
What are your top 3 goals for therapy?
*
Anything else you would like us to know before your first appointment (such as schedule preferences, pronouns, etc.)?
Shine PT does not bill any insurance company directly. Please note that if you are interested in reimbursement or credit for your payments from your insurance, please use the link below to find out if they require before answering the following:
I am not interested in reimbursement and did not inquire.
I am interested and will inquire.
I inquired and they do not require authorization.
I inquired and they do require authorization.
