Shockwave Intake Form

Extracorporeal Shockwave Therapy Patient Consent Form 

Suitability for ESWT (Extracorporeal Shockwave Therapy), also known as Softwave Tissue Regeneration Technologies. 

By answering the following questions, you will assist us to decide if you are suitable for ESWT. 

Have you been injected with cortisone this month?
Are you using a cardiac pacemaker?
Do you have cancer/tumor?
Do you have a skin infection?
Are you pregnant or do you suspect you may be pregnant?
Are you under 16 years of age?

RISK OF THIS PROCEDURE

A. Pain and Soreness. This is temporary and resolves after a few days. 

B. The FDA has labeled this a "Non-Significant Risk" therapy. 

Consent for Procedure

I have been fully informed of ESWT which the use of has been fully explained to me by my treating physician/staff, and I fully understand the nature of this treatment. I also confirm that I have been given the opportunity to discuss and clarify any concerns and that no guarantees have been made to me mostly for pain relief and may offer an improvement of function. I also understand foregoing treatment is not the first option for my condition and an alternate treatment has either already been provided or offered to me. 

Tell Us About You 

Marital Status:
Employment Status:
Student:
Emergency Contact is your:

Tell Us Why You're Here 

The Overall Severity of your Complaints/Concerns is:
The Overall Frequency is:
If your symptoms change, when are they worse:
Are your symptoms/pain getting:
Have you had recent treatment for this condition?
Have you had the same or similar problems in the past?
Do you have any additional complaints/concerns/health problems?
Please check all that apply:
Since your symptoms began, have you noticed any function changes:

Use the following key to mark your complaints on the diagram: 

Pain = P         Soreness = O        Burning = B         Numbness = N       Stiffness = X        Tingling = T

Weakness = W       Swelling = S       Radiating = R 

Mark on the Diagram:
On a Scale of 0 to 10, how would you rate your Pain/Symptoms today?

Please mark whether you NOW HAVE or had IN THE PAST any of the following conditions/illnesses: 

Your Activities of Daily Living and Work

Please indicate which activities of daily living are compromised by your current state of health:
How often does your job involve lifting?
Other job requirements (please check all that apply):
What is your primary work position?

Sickness, Injury and Accident History 

Include dates, descriptions and specify (right side, left side or bilaterally as applicable. 

Are you currently taking ANY over-the-counter medication:
Are you currently taking ANY prescription medication:

To the best of my knowledge the questions on this form have been accurately answered. I understand that providing incorrect or incomplete information can be detrimental to my health. It is my responsibility to inform Jurgens Chiropractic of any changes in my health status. 

Thank you for taking the time to fill out this form.

Our Location

Hours of Operation

Chiropractic Office Hours

Monday

9:00 am - 7:00 pm

Tuesday

9:00 am - 7:00 pm

Wednesday

9:00 am - 7:00 pm

Thursday

9:00 am - 7:00 pm

Friday

9:00 am - 7:00 pm

Saturday

10:00 am - 1:00 pm

Sunday

Closed

Chiropractic Office Hours

Monday
9:00 am - 7:00 pm
Tuesday
9:00 am - 7:00 pm
Wednesday
9:00 am - 7:00 pm
Thursday
9:00 am - 7:00 pm
Friday
9:00 am - 7:00 pm
Saturday
10:00 am - 1:00 pm
Sunday
Closed