Medical Evaluation Form for Therapy

Step 1 of 3

Patient's Name*

First Last

What Condition Are You Diagnosed with?*

Telephone or Cell Number*

Email*

Skype User Name

What is Your Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Your Gender*

Male

Female

Date Of Birth (DD/MM/YY)*

Patients Height*

Please Specify Feet/Inches or CM

Patients Weight*

Please Specify Pounds or KG

What is Your Occupation?

Your Personal Doctor in Your Home Country ( Primary Care Physician )

First Last

Office Phone for Your Primary Care Physician (In Case of Records Requests)

Name & Telephone Number of your Emergency Contact Person*

This Can be Family,Friend or Caretaker

Date of Initial Diagnosis*

When Were You Initially Diagnosed By A Medical Doctor?

Other Diagnoses & Dates

Please list All Other Medical Conditions As Completely As you can

How would you describe your current medical condition?*

Do you have or have you suffered from the followings:*

Choose all that apply (Use CMD or Shift for Multiple)

If YES to any choices above, please elaborate:

Are you Currently Taking Any of the Following Medications:*

Choose all that apply

Do you have any of the following Sensory/Motor/Smell/Vision Loss symptoms?

Choose ALL that apply or "None of the Above"

Do you have any of the following symptoms?*

Choose ALL that apply

Please list all medications you are currently taking, date started, date stopped, dose, and strength.*

Smoking

Amount per day

When started

When stopped

if NONE Please Write “NONE”

Alcohol

Type

Amount per day or week

if NONE Please Write “NONE”

Family History of Disease:*

Disease

Relationship

If NONE Please Write "NONE"

List all Nutritional Supplements You are Taking. Please Include Brand Names and Dosages*

If "NONE" please Write "NONE"

Please choose one of the followings which best describes your moving ability.*

Allergies, Vaccination, drugs, hay fever
Heart Problem
High Blood Pressure
Asthma
Lung Disease
Epilepsy
Psychiatric problems - nervousness, depression
Gastrointestinal problems
Liver Problems
Hepatitis A
Hepatitis B
Hepatitis C
Renal Problems
Kidney Problems
Musculoskeletal Problems
Osteoporosis
Osteoarthritis
Blood Disorder
Thrombosis
Diabetes Type1
Diabetes Type2
Thyroid Disorde
Menopause
HIV/AIDS
Cancer
Surgery
None of the above

Upper limbs
Upper limb
Lower limbs
Lower limbs
Thorax
Thorax
Pelvis
Pelvis
Face below eyes
Face below eyes
Face above eyes
Face above eyes
Eye Movement Affected
Eye Movement Affected
Loss of Sense of Smell
Left Eye Visual Field Loss
Left Eye Visual Field Loss
Right Eye Visual Field Loss
Right Eye Visual Field Loss
Mild Dementia
Moderate Dementia
Severe Dementia
Seizures
None of the above