Client Intake Form for Raleigh WaveTech Therapy Medical History & Consent Please complete the form in its entirety before your appointment. Patient Intake & Consent 2021 Please complete the form in its entirety before your appointment. First Name * Last Name * Birth Date * Street address / Apt Number City State Zip Phone Number * Email Address * Gender Select Female Male Other Ethnicity Select Asian/Pacific Islander Black/African-American Hispanic/Latino Native American White Other Unknown Type of ailment (use Ctrl+click to select more than one)? * Select Chronic Pain Erectile Dysfunction Sports Injury Urinary Incontinence or Frequency Do you frequently urinate at night? Select Yes No Medications & Allergies Are you currently taking medication, including over-the-counter and/or herbal medication? * Select Yes No If yes, list your current medications: Do you take vitamin supplements? * Select Yes No If yes, list the vitamin supplements: Do you have allergies? * Select Yes No Please list allergies including drug allergies: Past Medical History Diabetes? * Select Yes No If yes, what is your A1C? Thyroid disease (hypothyroid, hyperthyroid, Graves disease, thyroiditis, mass, goiter)? * Select Yes No Cancer? * Select Yes No Explain the type of cancer: If male, have you had a PSA test? Select Yes No Heart problems or Heart Disease? * Select Yes No High blood pressure? * Select Yes No What is your average blood pressure? Elevated cholesterol or triglycerides? * Select Yes No Ever examined by a cardiologist? * Select Yes No Kidney stones? * Select Yes No Arthritis in a weight-bearing joint (foot, ankle, knee, hip, back)? * Select Yes No Sleep apnea? * Select Yes No Do you smoke? * Select Yes No How many cigars/cigarettes per day? Do you consume alcoholic beverages? * Select Yes No How much alcohol do you consume per week? Are you aware of any other health concerns that are not listed above? * Select Yes No Please explain any other health concerns: Please list all surgeries you have had: Have you had prostate surgery? Select Yes No By submitting this form, I authorize and give my consent to WaveTech Therapy and its non-medical staff persons for evaluation and treatment of my Acoustic Wave Therapy program (also known as shockwave) in accordance with the WaveTech Therapy's program. I understand and am fully satisfied with the knowledge, that there are risks to any non-approved activity and program; including the program for shockwave both known and unknown and that it is not possible to guarantee or give assurance of a successful result. I acknowledge and accept these known and unknown general risks. I also understand and agree to follow program and recommended schedule without deviation. In addition, I also agree to faithfully disclose my complete medical history, all prescription and nonprescription medications that I am currently taking or plan to take during my program. Also, all over the counter medications, recreational drugs or social substances, herbs, and extracts will be disclosed and I agree to completely follow the recommendations presented by WaveTech. I also understand that the use of "social substances" such as tobacco, "street drugs," alcohol, and other types of otherwise non-described "social substances" may affect my results and program. I release WaveTech Therapy staff and company of any and all liability. I confirm that I have read this form in its entirety or it has been read to me if I have been unable to read it. I understand there are risks associated with participating in any program offered by WaveTech Therapy. * I agree I disagree I have been informed and fully understand that WaveTech is not a medical facility, not staffed by licensed medical professionals, shockwave therapy is not considered a medical procedure, as defined by the Sateís Medical Board or other regulating authority and has limited approved treatments from the Food and Drug Administration. WaveTech is not affiliated with any medical doctor, and I have been advised to consult with my physician before receiving any shockwave program. If I choose to receive such program performed on me then I have committed that I have discussed with a licensed medical professional or waive the need to proceed or discuss with a licensed medical professional or family member, or guardian. * I agree I disagree Submit Reset
