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  • Personal Information

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Sex

  • Note: DolorClast® Shockwave Therapy is intended for patients aged 18 and over.
     

  • Contact Information

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  • How did you hear about our clinic? (Check one):

  • Reason for Consulting

  • What is your primary reason for consulting today? (Please only select 1 body part for initial consultation).

  • DolorClast® Therapy Unit – Note: Shockwave therapy is not recommended for the neck.
    The cervical region is more delicate and anatomically complex than other areas of the body, with smaller, more sensitive structures and close proximity to the lungs, major blood vessels, and nerves. For this reason, applying shockwave in this area may carry increased risk and is not considered appropriate.

  • Side affected:

  • Nature of the Problem

  • Which best describes your concern? (check all that apply)

  • Symptom History

  • How long have you had this issue?
  • Onset was:

  • Pain & Functional Impact

  •    
  • What activities make your symptoms worse? (check all that apply)

  • Previous Care for This Issue

  • Have you tried any of the following? (check all that apply)
  • Did this provide lasting relief?

  • Relevant Medical History

  • Please check all that apply:

  • Medications

  • Are you currently taking:

  • **Please note: Shockwave therapy is not recommended for individuals who are taking prescription blood thinners. The use of low-dose ("baby") aspirin is permitted.

    If you are currently taking prescription blood thinners, please call our office to advise us. 

  • Treatment Goal

  • What is your main goal with Shockwave Therapy?
  • Do you have any other health concerns we should know about?

  • Thank you so much for filling out the Shockwave & Adjunct Therapies New Patient Health Questionnaire. We look forward to helping you with your specific health concerns and overall well-being!

    The Team at Santé Chiropractic and Wellness Centre
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