Dry Needle Medical History Questionnaire

Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Height
Weight
When did the problem begin
Are your symptoms…
Do you have pain?
- Yes
- No
Please rate pain 0-10 (0 no pain, 10 horrible pain)
Please enter a number from 0 to 10.
Have you had previous treatments?
Have you ever had any of the following conditions or diagnoses?*
List and Date Surgeries
List Medications