Please mark area(s) of injury or discomfort as shown in the example below. Make all areas with the appropriate symbols and indicate the degree of pain using a scale from 1 (discomfort) to 10 (extreme pain) Description Numbness Pins & Needles Burning Aching Stabbing → Symbol→ NNNN PPPP BBBB AAAA SSSS Do you: Take Supplements or Vitamins? Yes No Exercise? Yes No □ □ □ □ Are you on a special diet? Yes No Since: ____/____/____ □ □ Do you smoke? Yes No How much? _______ How long? __________ □ □ Are you wearing: Heel Lifts Sole Lifts Inner Soles Arch Supports □ □ □ □ What is the age of your mattress? ________ Is it comfortable? Yes No □ □ Are you taking Birth Control? Yes No For Women: □ □ Are you pregnant? Yes No How long? _____ Nursing? Yes No □ □ □ □ HEALTH HISTORY Are you taking any of the following medication? Nerve pills Pain killers (including aspirin) Muscle relaxers Stimulants □ □ □ □ Blood thinners Tranquillizers Insulin Other(s) ___________________ □ □ □ □ Do you have or ever had any of the following diseases or conditions? Y N Heart Attack/Stroke Y N Heart Surgery/Pacemaker Y N Heart Murmur Y N Congenital Heart Defect Y N Mitral Valve Prolapse Y N Artificial Valves Y N Alcohol/Drug Abuse Y N Venereal Disease Y N Hepatitis Y N HIV+/Aids Y N Shingles Y N Cancer Y N Frequent Neck Pain Y N Emphysema/Glaucoma Y N Anemia Y N High/Low Blood Pressure Y N Psychiatric Problems Y N Rheumatic Fever Y N Severe/Frequent Headaches Y N Kidney Problems Y N Ulcers/Colitis Y N Fainting/Seizures/Epilepsy Y N Sinus Problems Y N Asthma Y N Diabetes/Tuberculosis Y N Difficulty Breathing Y N Chemotherapy Y N Lower Back Problems Y N Artificial Bones/Joints Y N Arthritis Please list any other serious medical condition(s) you have or ever had:
Please mark area(s) of injury or discomfort as shown in the example below. Make all areas with the appropriate symbols and indicate the degree of pain using a scale from 1 (discomfort) to 10 (extreme pain) Description → Numbness Pins & Needles Burning Aching Stabbing Symbol→ NNNN PPPP BBBB AAAA SSSS Do you: Take Supplements or Vitamins? □ Yes □ No Exercise? □ Yes □ No Are you on a special diet? □ Yes □ No Since: ____/____/____ Do you smoke? □ Yes □ No How much? _______ How long? __________ Are you wearing: □ Heel Lifts □ Sole Lifts □ Inner Soles □ Arch Supports What is the age of your mattress? ________ Is it comfortable? □ Yes □ No For Women: Are you taking Birth Control? □ Yes □ No Are you pregnant? □ Yes □ No How long? _____ Nursing? □ Yes □ No HEALTH HISTORY Are you taking any of the following medication? □ Nerve pills □ Pain killers (including aspirin) □ Muscle relaxers □ Stimulants □ Blood thinners □ Tranquillizers □ Insulin □ Other(s) ___________________ Do you have or ever had any of the following diseases or conditions? Y N Heart Attack/Stroke Y N Heart Surgery/Pacemaker Y N Heart Murmur Y N Congenital Heart Defect Y N Mitral Valve Prolapse Y N Artificial Valves Y N Alcohol/Drug Abuse Y N Venereal Disease Y N Hepatitis Y N HIV+/Aids Y N Shingles Y N Cancer Y N Frequent Neck Pain Y N Emphysema/Glaucoma Y N Anemia Y N High/Low Blood Pressure Y N Psychiatric Problems Y N Rheumatic Fever Y N Severe/Frequent Headaches Y N Kidney Problems Y N Ulcers/Colitis Y N Fainting/Seizures/Epilepsy Y N Sinus Problems Y N Asthma Y N Diabetes/Tuberculosis Y N Difficulty Breathing Y N Chemotherapy Y N Lower Back Problems Y N Artificial Bones/Joints Y N Arthritis Please list any other serious medical condition(s) you have or ever had:
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