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Dr. Al Glaza 548 Nautical Drive Suite 204 Lake Wylie, South Carolina 29710 (803) 831-2345

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Date

Name

Birth Date

Male Female

Address

City

State

Zip

Home Phone

Cell Phone

Employer

What is your present complaint?

When did it start?

What started this condition?

What sensations do you feel?

Numb

Tingling

Pins-Needles

Spasms

Other

Is this work related?

Accident related?

What have you done to help with your condition?

Your pain Scale 1-10

How would you describe what your feeling?

Sharp

Dull

Aching

Burning

Numbness

Radiating

Sore

Tender

Weak

Stiff

Other

Have you had any surgeries?

Yes No

If so, what/when?

Have you fallen?

Yes No

Are you pregnant?

Yes No

Due Date

Are you a

Smoker Former Smoker Never Smoked

Do you have a pacemaker?

Yes No

What prescription medications are you taking?

Are you allergic to any prescription medications?

Do you have new health insurance? If yes, please add a front and back copy of your card as a PDF file.

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