Name:*
Age:*
Date of Birth:*
 / 
 / 
Gender:
Marital Status:
Religion:

PLEASE ANSWER THE FOLLOWING QUESTIONS.

Do you practice any kind of physical activity?
If yes please specify:

Have you traveled lately?
Please specify if yes:

HELP US KNOW A BIT MORE ABOUT YOUR PATHOLOGICAL BACKGROUND

ALLERGIES:
List Allergies (known):

Bone Fractures:
List Fractures:

Surgeries:
List Surgeries:

Chronic Degenerative Diseases:
Please list :

Functional Disability:
Specify:

Smoking

Alcoholism

Drug Addiction
Please list:

Please specify your current condition including signs and symptoms and how your condition has evolved.

Please name all the medications you are currently taking (separated by comma).

Are you currently in pain:
If you are in pain please select your pain level being 10 the highest:

Word Verification: