ReVive Bodyworks Intake Form
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Let's talk about your pain:
How long have you experienced this pain?
3 months or less
3-11 months
1 -2 years
Can't remember life without it
What is the exact location of the pain?
What is the nature of the pain?
Constant
Comes and Go
Dull
Burning
Sharp (pins and needles)
Numb
Spasms
Deep ache
What makes the symptoms better?
Characters:
0
/255
What makes the symptoms worse:
Characters:
0
/255
Can you reproduce the pain?
Yes
No
Not sure
How does the pain affect your life?
Have you had the following:
Automobile accidents
Whiplash
Concussions
Head trauma
Injuries
Injury
Add Another Injury
Surgeries
Surgery
Add Another Surgery
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