Painless Trigger Point
Intake Form
Please complete all fields in the form below. They are all vital. If a field does not apply, enter n/a
If you have any questions don't hesitate to call or email Raj at 310-930-5884 or
raj@painprof.com
Firstname
*
:
Lastname
*
:
Consultation Type
*
:
choose one
Online
in Person
Home(landline)
*
:
Cell
:
Email:
*
Address:
City
*
:
State
*
:
Zip:
Birthdate
*
:
Profession
*
:
Sex
*
:
M
F
Current Sport/Exercise
*
:
Previous Sport/Exercise
:*
Attention Area/s:
*
Recent Injury
*
Old Injury:
*
Ailment Period
*
:
1 - 11 months
1 - 5 years
6 - 10 years
10 - 20 years
History
*
Describe your observtions re the development of the condition in each of your affected areas from when you first noticed it, even in its mildest form. This information is vital for an acurate evaluation.
Previous Treatments and Results
*
:
Your Short-term and Ultimate Goals
*
:
Hand Strength
*
:
average
strong
weak
have pain
stiff
Trigger Point Knowledge
*
:
no knowledge of
good knowledge
some knowledge
own T.P. Workbook