Radial Shockwave Therapy

Advantage Family Chiropractic

Call or text 618-234-6000
Fax 618-234-6009

Patient Information

Patient Name

Date of birth

Age

Gender

Occupation

Contact Information

Phone number

Email address

Address

City

State

Zip

Emergency Contact

Add another emergency contact

Medical History

You MAY NOT BE a candidate for Radial Shockwave Therapy IF you are currently receiving ACTIVE treatment for cancer (chemotherapy), had recent injections for your complaint (in the last 6-12 weeks) or have a coagulation/blood clotting disorder.

Describe anything you think might have caused the symptoms.

Examples: Working out, posture, sleeping, etc.

Have you had any past fractures, sprains, or breaks? If so, include the type of injury, location on your body, and when the injury occurred.

Mark the areas on the image where you are experiencing symptoms.

Past Medical History

What medications are you taking (if any) and for what conditions?

Do you have any medication allergies?

Previous Surgeries or Injuries

Previous Treatments

Physical Therapy, Chiropractic, Prescription Medicine, Injections, Surgery

Effectiveness of previous treatments

Physical Therapy, Chiropractic, Prescription Medicine, Injections, Surgery

List any upcoming surgeries or procedures

Surgeries, Steroid injections, Therapies

Do you have any pre-existing medical conditions?

Example: Asthma, heart conditions, etc

Is there anything else regarding your medical history that we should be aware of?

Lifestyle

Please rate on a scale of 1-10 (1 being the lowest and 10 being the highest)

Are you pregnant?

Yes No Not sure

If yes, how far along?

Do you drink alcohol?

Regularly Occasionally No

Do you have a healthy and balanced diet?

Regularly Occasionally No

Do you smoke?

Regularly Occasionally No

Do you exercise?

Regularly Occasionally No

How are your stress levels?

High Moderate Low

1. Quality of Life

How does this affect your daily activities, work, sleep, hobbies?

2. Activities of Daily Living

Are you able to perform daily activities (walking, dressing, bathing) without difficulty?

yes No

If No, which activities are affected?

Do you experience pain/discomfort during daily activities?

yes No

If yes, please specify.

3. Expectations and Goals

What do you hope to achieve with Radial Shockwave Therapy?

i.e.. pain relief, improved function

Consent and Agreement

I confirm that the information provided is accurate. I consent to a physical exam of my areas of complaint. I understand the exam may include video evaluation.

Signature

Date

For Office Use ONLY- Do not fill out anything below this line

Doctors Findings

By signing below, you acknowledge that you understand and accept the risks, benefits and cost of radial shockwave therapy and consent to having this therapy administered.

Signature

Trial Treatment Notes- Radial Shockwave Therapy

Treatment area

BAR Energy

HZ Frequency

Head

# Shocks

Protocol

Tissue Breakdown

Stimulate Healing

Pain Relief

Service Codes

99201

0101T

X-ray

Discount ________%

Treatment Number

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Radial Shockwave Therapy

Shockwave therapy treats chronic conditions by delivering penetrating shockwaves deep into soft tissue, inducing micro-trauma and triggering a new inflammatory response. This prompts the body's natural healing mechanisms. The emitted energy also stimulates cells to release biochemicals, enhancing healing and fostering the formation of new blood vessels in the treated area. Shockwave therapy treats conditions with calcifications, like tendons or joints, through cavitation. This process creates and collapses microscopic gas bubbles in calcified deposits, breaking them down. This restores tissue function and relieves symptoms of calcification related conditions. Common Conditions: Tennis Elbow, Golfers Elbow, De Quervain's Disease, Trigger Finger, Carpal Tunnel, Plantar Fasciitis, Neuropathy, Shoulder Calcific Tendonitis, Achilles Tendinopathy, Patellar Tendinopathy, Sciatica, Bone Spurs and SO MUCH MORE!