Patient Summary Form Patient Summary Patient's Name(Required) First Last Email(Required) Date of Birth(Required) MM slash DD slash YYYY Symptoms began on:(Required) MM slash DD slash YYYY Briefly describe your symptoms:(Required)How did your symptoms start?(Required)Average pain intensity the last 24 hours(Required) 0 = no pain and 10 = worst painAverage pain intensity the last week(Required) 0 = no pain and 10 = worst painHow often do you experience your symptoms?(Required) 1 - Constantly (76%-100% of the time) 2 - Frequently (51%-75% of the time) 3 - Occasionally (26% - 50% of the time) 4 - Intermittently (0%-25% of the time) How much have your symptoms interfered with your usual daily activities?(Required) 1 - Not at all 2 - A little bit 3 - Moderately 4 - Quite a bit 5 - Extremely (including both work outside the home and housework)How is your condition changing, since care began at this facility?(Required) 0 - N/A — This is the initial visit 1 - Much worse 2 - Worse 3 - A little worse 4 - No change 5 - A little bit better 6 - Beter 7 - Much better In general, would you say your overall health right now is...(Required) 1 - Excellent 2 - Very good 3 - Good 4 - Fair 5 - Poor Singer's Name(Required) First Last CAPTCHA Recent News Spring Past Your InjurySpring is here, and with it comes the excitement of marathon season. […] COVID Long HaulersThere is a subset of individuals who experience prolonged symptoms of COVID-19 for weeks, if not months, despite having survived the initial infection. These individuals have dubbed themselves COVID Long Haulers or those living with long COVID. […] Back to School: How to Prevent Sports InjuriesComing back to a new school year for some may not only mean returning to […] PatientsNew Patients New Patient Registration Missed Appointments Insurance We Accept Billing Policies Insurance Resources Pay Online Medical Records Release POST PT Telehealth Appointments