PATIENT INFORMATION. Last Name: First Name: Address: City/State/Zip: Phone: (H): (W): (C): Date of Birth: Gender: Male Female

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PATIENT INFORMATION Date Last Name: First Name: Address: City/State/Zip: Phne: (H): (W): (C): Email: Date f Birth: Gender: Male Female EMERGENCY CONTACT INFORMATION Last Name First Name Middle Initial Phne Number(s): Nearest Relative/Friend Nt Living With Yu: Phne Number(s): Abve infrmatin will be used fr verificatin and emergency purpses nly. Hw did yu hear abut RestraLife? Referral Physician Friend Patient TV Cmmercial (News 13) Space Cast Business Internet Search/Website Seminar Attended Indian River Fitness Carrabba s Newspaper Article Insert Bareft Tattler Facebk Calilu / PC Keat s Bran s Saving Safari Mail Insert Senir Scene Glf Scre Card 304 S. Harbr City Blvd. Suite 100. Melburne FL 32901 [] (321) 610-1848 1

PATIENT HEALTH QUESTIONNARE Please list all peratins yu have had: Medicatins: Previus treatment fr cnditins: Current Primary Care Physician: Physician Cntact Phne Number: Have yu ever been treated by a pain center? If yes, please list dctr. D yu smke? If s, hw much? _ D yu drink alchl? If s, hw much? _ D yu use recreatinal drugs? If s, hw much? _ Please list all drug allergies (medicatins, inhalants, fds, cntact allergies): Please describe any ther prblem which may nt have been cvered abve and which yu wuld like the clinician t knw: 2

Patient Name: Mark the areas where yu are experiencing pain. Please circle the amunt f pain yu are in: 0 (n pain) t 10 (severe pain). 0 1 2 3 4 5 6 7 8 9 10 N Pain Wrst Pain PRIMARY prblem* that brught yu t RestraLife? SECONDARY cmplaints* r areas f pain? 3

* Please label n the diagram abve the primary and secndary areas f pain Head and Neck Altered sense f smell Nasal bstructin Snring Nasal discharge Nsebleeds Facial Pain Lcal skin lesins that have changed recently Lumps r swelling Eyes Duble visin/blurred visin Dry eyes Itchy/watery eyes Glaucma Flashing lights Flaters Retinal prblems Are yur eyes matted/dry in the a.m.? Respiratry System Chrnic cugh Wheezing, asthma Histry f TB r lung cancer Allergies _ Neurlgic Headaches Transient lss f visin Seizures Strkes Head injury Anxiety r depressin _ 4

Cardivascular System Heart Murmur Chest Pain Swelling f the ankles Shrtness f breath n exertin Heart surgery r angiplasty High bld pressure _ Endcrine Diabetes Over r underactive thyrid _ Urgenital Frequent urinatin Prstate prblems Kidney Disease Gastrintestinal Heartburn r Ulcers Jaundice, Liver Disease, Hepatitis _ General Skin Cancer Skin Diseases Bleeding Disrder Previus bld transfusin Bld clts Have yu ever been n Acutane? Have yu ever had cld sres? 5

Are yu a candidate fr Laser Therapy? Laser therapy is an FDA-cleared mdality fr the treatment f pain and inflammatin. The therapy causes a temprary increase f micrcirculatin. Increased micrcirculatin and the reductin f inflammatin can prvide relief fr many acute and chrnic cnditins. This frm is a tl t help yur clinician determine if yu are a candidate fr laser therapy. If yu answer yes t any f these questins yu will need t discuss details f yur cnditin with yur clinician. Please check r t the questins belw D yu have a pacemaker r any ther implanted devices? Are yu pregnant? D yu have cancer? Are yu taking medicatins that may increase yur sensitivity t light? Have yu had a sterid injectin in the last 7 days? Nt related t Laser Therapy: D yu have any knwn allergies r sensitivities t DMSO (Dimethyl Sulfxide)? (Stem Cell Patients Only) D yu have any knwn allergies t prducts frm birds such as feathers, eggs and/r pultry? (HA Patients Only) Patient signature: Date: Printed Patient Name: Ntes: 6

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