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Thermographic Health Advantage
Preventative Health Screening Designed for Your Well-Being
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Accident or Injury Questionnaire
This form must be completed for all personal injury or accident cases.
Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Address
*
City
*
State
*
Zip Code
*
Email Address
*
Phone
*
Please include area code.
(###)
###
####
Please describe the primary pain you are currently experiencing
Has your current injury or condition been diagnosed by any of the following test?
*
Please bring a copy of all pertinent reports to your appointment.
X-ray
MRI
CT Scan
EMG
Nerve Blocks
Discography
Myelogram
Bone scan
Ultrasound
NCV: nerve conduction velocity
None
Secondary pain ( If any )
Are you experiencing numbness or the sensation of pins and needles?
Was your pain caused by an accident or injury?
Yes
No
Details of the accident or injury
What triggers the pain?
Does anything relieve the pain?
Have you had any treatments for this condition or pain?
Thank you!