Please answer each question as completely as possible 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your personal information, including your name, age, height, weight, sex, date of birth, school grade, and the name and fax number of your primary care physician.
3. Indicate your dominant hand and specify the body part that needs examination by checking the appropriate box.
4. Describe how and when the injury occurred or when symptoms began. Include details such as the date of injury and type of sport involved.
5. Check any symptoms you noticed at the time of injury and list any treatments you have received for this problem along with their results.
6. Provide a detailed description of your pain, including its nature (sharp, aching) and location. Also note what aggravates your symptoms.
7. Complete the health history section by detailing any drug allergies, medical illnesses, previous surgeries, current medications, family history, and social habits.
8. Finally, sign the patient consent and waiver form to acknowledge responsibility for charges associated with your appointment.

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