Appointment - Intake Form



 No More Pain - The ARP Way

CAN: 1.416.770.1757      USA: 1.206.497.1500      Tool Free Fax:  1.855.853.9659  (USA, CAN & Latin)


Preset Field - Do Not Change:

Your Full Legal Name:

Please check all present symptoms related to your current condition:

Are you pregnant:     (If YES, not qualified)

Any pacemaker or ICD: (If YES, not qualified)

Do you have a Blood clot or any history of blood clots: (If YES, not qualified)

NOTE: If you answered YES to any of the above questions we can not help you.

Where Is The Location Of Your Pain:
Rate The Intensity Of Your Pain When Doing A Movement That Bothers You:


Preset Field - Do Not Change:
When did your complaint/symptoms begin:
Describe your complaint/symptoms:   

Where is the location of your pain:     

What does your pain feel like:
What was the cause of the symptoms:

What activity bothers you the most:    

What activity lessens your symptoms: 

How have symptoms progressed:        

What treatments have you done (check all that apply):
Massage    Medication    Physical Therapy    Rest / Ice / Compression
Surgery Chiropractic Alternative


Preset Field - Do Not Change:

Have you seen a doctor because of your current condition:   
If so, what was the result:

Do you have any allergies, if so list them:


Preset Field - Do Not Change:
Have you had any diagnostic tests performed by any Doctors (check all that apply):
MRI    X-Rays    Lab Work    Functional Testing   Psychological Testing    Electro diagnostics    Others)
If so, what were the results of the test :

Are there any additional comments about your condition that you feel would be important for us to know:


Year of Birth: Today's Date:
Home Address :
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Best Time To Call To Setup An Appointment With You:
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