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Today's Date: July 26, 2024

Welcome!

Thank you for partnering with me as a consultant to help you resolve your physical limitations and reach your full potential as a human being! I am committed to providing you with the best possible evaluation, manual therapy treatment, and ongoing consultation regarding how you can best meet your goals, whatever they may be. My goal is help you identify the root cause of what is limiting you in sport and in life! That process starts with great communication so please fill out this brief form completely so I can learn a bit more about you prior to our first session. 

Notice Of Client Information Practices

This notice describes how medical information about you may be used or disclosed and how you may get access to information. Please read it carefully.

The Legal Duty Of Merrill Performance:

Merrill Performance, LLC is required by law to protect the privacy of your personal health information, provide this notice about our information practices, and follow the information practices that are described herein.

Uses And Disclosures Of Health Information

Merrill Performance, LLC uses your personal health information primarily for treatment, helping you obtain reimbursement for treatment, internal administrative activities, and evaluating the quality of the service we provide. For example, Merrill Performance may use your personal health information to contact you to provide appointment reminders or additional information about your health that may be of interest to you.

Merrill Performance may also use or disclose your personal health information without prior authorization for public health purposes, auditing purposes, for research studies, and for emergencies. We also provide information when required by law. You understand that the information provided based on the above may be re-disclosed to another party by the authorized recipient, and that Merrill Performance, LLC has no control over that additional disclosure and cannot protect the information after it is released.

In any other situation, the policy of Merrill Performance, LLC is to obtain your written authorization before disclosing your personal health information. If you provide us with written authorization to release your information for any reason, you may later revoke that authorization to stop future disclosures at any time.

Merrill Performance my change its policy at any time. When changes are made, a new Notice of Information Practices will be provided to you at your next visit. You may also request a copy of our Notice of Information Practices at any time.

Clients Individual Rights

You have the right to review or obtain a copy of your personal health information at any time. You have the right to request that we correct any inaccurate or incomplete information in your records. You also have the right to request a list of instances where we have disclosed your personal health information for reasons other than treatment, payment, or other related administrative purposes.

You may also request in writing that we not use or disclose your personal health information for treatment, payment, and administrative purposes except when specifically authorized by you, when required by law or in emergency circumstances. Merrill Performance will consider such requests on a case by case basis, but the practice is not legally required to accept them.

Concerns And Complaints

If you are concerned that Merrill Performance may have violated your privacy rights or if you disagree with any decisions we have made regarding access of disclosure of your personal health information, please contact Charlie Merrill at the address listed below. You may also send a written complaint to the US Department of Health and Human Services.

Consent & Release For Trigger Point Dry Needling (TDN) Procedure

During the course of treatment for many of my clients, I commonly use a technique called trigger point dry needling (TDN). This technique may or may not apply to your situation, but can be helpful in resolving many types of biomechanical issues, movement dysfunctions, physical limitations, performance deficits, sub-acute pain, and chronic pain.

This technique involves placing a tiny acupuncture needle into a muscle or muscles in order to release shortened bands of muscle and decrease trigger point activity. This can help resolve pain and muscle tension, and promote healing. I have helped many patients with this technique. This is NOT traditional Chinese Acupuncture, but instead a medical treatment that relies on a medical diagnosis to be effective. Ive completed the highest level of trigger point dry needling training required in the state of Colorado including both Level I and Level II competency. This training is above and beyond my professional training as a licensed Physical Therapist.

This form is a consent and general release of medical liability for this procedure. By signing this form, you agree not to hold Charlie Merrill, MSPT or Merrill Performance, LLC liable for any complications that may arise from the usual application of this procedure. TDN is a valuable treatment for musculoskeletal dysfunction and/or pain. Like any treatment, there are possible complications. While complications are rare, they are real and must be considered prior to giving consent for treatment.

Risks Of The Procedure

The most serious risk associated with TDN is accidental puncture of a lung (pneumothorax). If this were to occur, it may likely require a chest x-ray and no further treatment. The symptoms of shortness of breath may last for several days to weeks. A more severe puncture can require hospitalization and re-inflation of the lung. This is a rare complication, and in skilled hands it should not be a concern.

Other risks include injury to a blood vessel causing a bruise, infection, and/or nerve injury. Bruising is a common occurrence and should not be a concern unless you are taking a blood thinner or have a bleeding disorder. Additional possible complications include possible increased pain or other symptoms. As the needles are very small and do not have a cutting edge, the likelihood of any significant trauma from TDN is unlikely.

Prior to performing TDN you will be verbally consented. This means you will be asked if you want to proceed. If you state yes, you will not be asked to sign another consent and release form. This form will be kept on file.

Please consult with Charlie Merrill, MSPT if you have any questions regarding the treatment above.

Patient Signature:

Clinic Policies

Payment is due at the time of service. Payment can be made by either check, Zelle, Venmo, Apply Pay/Apple Cash, Paypal, or credit card (which will include a 2.75% service charge). The initial 90 minute evaluation costs $300 and follow up appointments cost $200 for 60 minutes or $125 for 30 minutes. In home health is billed on a per case basis.

For any checks that do not clear, a fee of $25 shall be assessed. All costs associated with the collection of any debt shall be paid for by the patient, including any attorney fees.

Merrill Performance is not responsible for insurance reimbursement for treatment. You are welcome to submit an invoice for out of network reimbursement yourself. An invoice will be provided via email by request. The same invoice can be used to access your HSA/FSA.

Supplies will charged as needed, with your approval, above and beyond the regular visit price. Supplies include things like tape, balls, band, etc. that may be helpful toward you getting well.

You are responsible for canceling appointments with me a minimum or 12 hours in advance by phone (303.717.8351), email (charlie@mperformance.com), or text to avoid cancellation fees. a $50 fee will be assessed for missed appointments or late cancellations.

In-person and virtual clients in Colorado may request a superbill to self-submit for out-of-network reimbursement. These visits will be coded and billed as physical therapy. Virtual clients out of state or out of the country may not submit for reimbursement. These client visits are considered "coaching" rather than physical therapy and so are not reimbursable.

Patient Signature:

General Request For Consent To Treatment

By signing below, I am requesting and consenting to a physical evaluation and treatment to be performed by Charlie Merrill, MSPT, a licensed Physical Therapist (CO license #7010). I recognize that the practice of manual therapy is a science, and therefore acknowledge that no guarantees have been, or can be made, regarding the outcome or success with manual therapies.

Patient Signature:

HIPPA Compliance

I have read and fully understand Merrill Performances Notice of Client Information Practices as set forth herein. I understand that Merrill Performance may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality of service, and any administrative operations related to treatment or payment. I understand that I have the right to restrict how my personal health information is used and disclosed for treatment, payment, and administrative operations if I notify the practice. I also understand that Merrill Performance will consider requests for restriction on a case-by-case basis, but does not have to agree to requests for restrictions. I hereby consent to the use and disclosure of my personal health information for purposes as noted in Merrill Performances Notice of Information Practices as set forth herein. I understand that the information provided based on the above may be re-disclosed to another party by the authorized recipient, and that Merrill Performance, LLC has no control over that additional disclosure and cannot protect the information after it is released.

Patient Signature:

Merrill Performance, LLC - 1836 Baseline Road - Boulder, CO 80302 - 303.717.8351 - Charlie@Mperformance.com

First Client's Name

First Name*

Middle Name

Last Name*
First Client's Date of Birth*
First Client's Information

Home Phone:

Cell Phone:

Work Phone:

Employer:

Occupation:

My experience is that filling out this form is a helpful exercise that will allow you to get clear about your symptoms before our visit.  It will help you and I to problem solve as a team and to get you well as quickly as possible.  It will also leave more time for treatment during our first session.  Thank you for taking a few minutes to fill this out thoughtfully and completely.  We'll have time to review and discuss this in person if you need to clarify anything.

Current Limitations


Why are you seeking evaluation and treatment?

Please list the major problem(s) of symptom(s) that you would like to address.

How long have you had symptoms?

When did they start?

What caused the symptoms originally?

Are the symptoms constant or do they come and go?

How have your symptoms changed over time (better, worse, moving around, spreading)

What makes you feel worse?

What makes you feel better?

Any major life changes or stress around family, work, living situation, or health around the time your symptoms started?

Any major life change or stress around family, work, living situation, or health recently or when your symptoms flared back up?

Please list the doctors, PTs, chiropractors, etc you have seen for this condition and list the diagnoses they have made.

Please list the treatments you have had for this symptom and describe how long they provided relief

Tell me what you understand about your current problem

I find people are intuitive about their bodies. Tell me your theory about what is making you hurt?

What do you know about your diagnosis from others or from your own research?

How do you feel I can help?

Past Pain History


What medications do you currently take? Please list.

Are you allergic to any medications? If yes, please list them.

Have you had any past injuries? If yes, please list them with approximate dates.

Have you had any surgeries or hospitalizations? If yes, please list them with approx.dates

What kind of work do you do currently now and has that changed recently?

Family history:

Next to the appropriate person, please list any disorders/illnesses that run in your family.   



Father:

Mother:

Sisters:

Brothers:

Children:

What WORDS would you use to describe your father (growing up and now)?

What WORDS would you use to describe your mother (growing up and now)?

Review of Health Systems
For each of the following, state 'YES' if you have had this symptom or condition and indicate the year it began and if it is still present.


1. Heartburn, acid reflux

2. Ulcer symptoms or stomach pains

3. Hiatal hernia

4. Irritable bowel syndrome

5. Colitis, spastic colon

6. Tension headache

7. Migraine headache

8. Eczema

9. Anxiety symptoms and/or panic attacks

10. Depression

11. Obsessive-compulsive thought patterns

12. Eating disorders

13. Insomnia or trouble sleeping

14. Fibromyalgia

15. Bell's palsy, facial paralysis

16. Back pain

17. Neck pain

18. Shoulder pain

19. Repetitive stress injury

20. Reflex sympathetic dystrophy (RSD)

21. Temporo-mandibular joint syndrome (TMJ)

22. Chronic tendonitis

23. Carpal tunnel syndrome

24. Trigeminal neuralgia, facial pain

25. Numbness, paresthesias

26. Fatigue or Chronic fatigue syndrome

27. Palpitations

28. Chest pain

29. Hyperventilation

30. Spastic bladder

31. Interstitial cystitis

32. Prostate problems

33. Pelvic pain

34. Muscle tenderness

35. Tachycardia or low blood pressure

36. Tinnitus

37. Dizziness

38. Other symptoms (please list)
First Client's Signature*
Second Client's Name

First Name*

Middle Name

Last Name*
Second Client's Date of Birth*
Second Client's Information

Home Phone:

Cell Phone:

Work Phone:

Employer:

Occupation:

My experience is that filling out this form is a helpful exercise that will allow you to get clear about your symptoms before our visit.  It will help you and I to problem solve as a team and to get you well as quickly as possible.  It will also leave more time for treatment during our first session.  Thank you for taking a few minutes to fill this out thoughtfully and completely.  We'll have time to review and discuss this in person if you need to clarify anything.

Current Limitations


Why are you seeking evaluation and treatment?

Please list the major problem(s) of symptom(s) that you would like to address.

How long have you had symptoms?

When did they start?

What caused the symptoms originally?

Are the symptoms constant or do they come and go?

How have your symptoms changed over time (better, worse, moving around, spreading)

What makes you feel worse?

What makes you feel better?

Any major life changes or stress around family, work, living situation, or health around the time your symptoms started?

Any major life change or stress around family, work, living situation, or health recently or when your symptoms flared back up?

Please list the doctors, PTs, chiropractors, etc you have seen for this condition and list the diagnoses they have made.

Please list the treatments you have had for this symptom and describe how long they provided relief

Tell me what you understand about your current problem

I find people are intuitive about their bodies. Tell me your theory about what is making you hurt?

What do you know about your diagnosis from others or from your own research?

How do you feel I can help?

Past Pain History


What medications do you currently take? Please list.

Are you allergic to any medications? If yes, please list them.

Have you had any past injuries? If yes, please list them with approximate dates.

Have you had any surgeries or hospitalizations? If yes, please list them with approx.dates

What kind of work do you do currently now and has that changed recently?

Family history:

Next to the appropriate person, please list any disorders/illnesses that run in your family.   



Father:

Mother:

Sisters:

Brothers:

Children:

What WORDS would you use to describe your father (growing up and now)?

What WORDS would you use to describe your mother (growing up and now)?

Review of Health Systems
For each of the following, state 'YES' if you have had this symptom or condition and indicate the year it began and if it is still present.


1. Heartburn, acid reflux

2. Ulcer symptoms or stomach pains

3. Hiatal hernia

4. Irritable bowel syndrome

5. Colitis, spastic colon

6. Tension headache

7. Migraine headache

8. Eczema

9. Anxiety symptoms and/or panic attacks

10. Depression

11. Obsessive-compulsive thought patterns

12. Eating disorders

13. Insomnia or trouble sleeping

14. Fibromyalgia

15. Bell's palsy, facial paralysis

16. Back pain

17. Neck pain

18. Shoulder pain

19. Repetitive stress injury

20. Reflex sympathetic dystrophy (RSD)

21. Temporo-mandibular joint syndrome (TMJ)

22. Chronic tendonitis

23. Carpal tunnel syndrome

24. Trigeminal neuralgia, facial pain

25. Numbness, paresthesias

26. Fatigue or Chronic fatigue syndrome

27. Palpitations

28. Chest pain

29. Hyperventilation

30. Spastic bladder

31. Interstitial cystitis

32. Prostate problems

33. Pelvic pain

34. Muscle tenderness

35. Tachycardia or low blood pressure

36. Tinnitus

37. Dizziness

38. Other symptoms (please list)
Third Client's Name

First Name*

Middle Name

Last Name*
Third Client's Date of Birth*
Third Client's Information

Home Phone:

Cell Phone:

Work Phone:

Employer:

Occupation:

My experience is that filling out this form is a helpful exercise that will allow you to get clear about your symptoms before our visit.  It will help you and I to problem solve as a team and to get you well as quickly as possible.  It will also leave more time for treatment during our first session.  Thank you for taking a few minutes to fill this out thoughtfully and completely.  We'll have time to review and discuss this in person if you need to clarify anything.

Current Limitations


Why are you seeking evaluation and treatment?

Please list the major problem(s) of symptom(s) that you would like to address.

How long have you had symptoms?

When did they start?

What caused the symptoms originally?

Are the symptoms constant or do they come and go?

How have your symptoms changed over time (better, worse, moving around, spreading)

What makes you feel worse?

What makes you feel better?

Any major life changes or stress around family, work, living situation, or health around the time your symptoms started?

Any major life change or stress around family, work, living situation, or health recently or when your symptoms flared back up?

Please list the doctors, PTs, chiropractors, etc you have seen for this condition and list the diagnoses they have made.

Please list the treatments you have had for this symptom and describe how long they provided relief

Tell me what you understand about your current problem

I find people are intuitive about their bodies. Tell me your theory about what is making you hurt?

What do you know about your diagnosis from others or from your own research?

How do you feel I can help?

Past Pain History


What medications do you currently take? Please list.

Are you allergic to any medications? If yes, please list them.

Have you had any past injuries? If yes, please list them with approximate dates.

Have you had any surgeries or hospitalizations? If yes, please list them with approx.dates

What kind of work do you do currently now and has that changed recently?

Family history:

Next to the appropriate person, please list any disorders/illnesses that run in your family.   



Father:

Mother:

Sisters:

Brothers:

Children:

What WORDS would you use to describe your father (growing up and now)?

What WORDS would you use to describe your mother (growing up and now)?

Review of Health Systems
For each of the following, state 'YES' if you have had this symptom or condition and indicate the year it began and if it is still present.


1. Heartburn, acid reflux

2. Ulcer symptoms or stomach pains

3. Hiatal hernia

4. Irritable bowel syndrome

5. Colitis, spastic colon

6. Tension headache

7. Migraine headache

8. Eczema

9. Anxiety symptoms and/or panic attacks

10. Depression

11. Obsessive-compulsive thought patterns

12. Eating disorders

13. Insomnia or trouble sleeping

14. Fibromyalgia

15. Bell's palsy, facial paralysis

16. Back pain

17. Neck pain

18. Shoulder pain

19. Repetitive stress injury

20. Reflex sympathetic dystrophy (RSD)

21. Temporo-mandibular joint syndrome (TMJ)

22. Chronic tendonitis

23. Carpal tunnel syndrome

24. Trigeminal neuralgia, facial pain

25. Numbness, paresthesias

26. Fatigue or Chronic fatigue syndrome

27. Palpitations

28. Chest pain

29. Hyperventilation

30. Spastic bladder

31. Interstitial cystitis

32. Prostate problems

33. Pelvic pain

34. Muscle tenderness

35. Tachycardia or low blood pressure

36. Tinnitus

37. Dizziness

38. Other symptoms (please list)
Fourth Client's Name

First Name*

Middle Name

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Information

Home Phone:

Cell Phone:

Work Phone:

Employer:

Occupation:

My experience is that filling out this form is a helpful exercise that will allow you to get clear about your symptoms before our visit.  It will help you and I to problem solve as a team and to get you well as quickly as possible.  It will also leave more time for treatment during our first session.  Thank you for taking a few minutes to fill this out thoughtfully and completely.  We'll have time to review and discuss this in person if you need to clarify anything.

Current Limitations


Why are you seeking evaluation and treatment?

Please list the major problem(s) of symptom(s) that you would like to address.

How long have you had symptoms?

When did they start?

What caused the symptoms originally?

Are the symptoms constant or do they come and go?

How have your symptoms changed over time (better, worse, moving around, spreading)

What makes you feel worse?

What makes you feel better?

Any major life changes or stress around family, work, living situation, or health around the time your symptoms started?

Any major life change or stress around family, work, living situation, or health recently or when your symptoms flared back up?

Please list the doctors, PTs, chiropractors, etc you have seen for this condition and list the diagnoses they have made.

Please list the treatments you have had for this symptom and describe how long they provided relief

Tell me what you understand about your current problem

I find people are intuitive about their bodies. Tell me your theory about what is making you hurt?

What do you know about your diagnosis from others or from your own research?

How do you feel I can help?

Past Pain History


What medications do you currently take? Please list.

Are you allergic to any medications? If yes, please list them.

Have you had any past injuries? If yes, please list them with approximate dates.

Have you had any surgeries or hospitalizations? If yes, please list them with approx.dates

What kind of work do you do currently now and has that changed recently?

Family history:

Next to the appropriate person, please list any disorders/illnesses that run in your family.   



Father:

Mother:

Sisters:

Brothers:

Children:

What WORDS would you use to describe your father (growing up and now)?

What WORDS would you use to describe your mother (growing up and now)?

Review of Health Systems
For each of the following, state 'YES' if you have had this symptom or condition and indicate the year it began and if it is still present.


1. Heartburn, acid reflux

2. Ulcer symptoms or stomach pains

3. Hiatal hernia

4. Irritable bowel syndrome

5. Colitis, spastic colon

6. Tension headache

7. Migraine headache

8. Eczema

9. Anxiety symptoms and/or panic attacks

10. Depression

11. Obsessive-compulsive thought patterns

12. Eating disorders

13. Insomnia or trouble sleeping

14. Fibromyalgia

15. Bell's palsy, facial paralysis

16. Back pain

17. Neck pain

18. Shoulder pain

19. Repetitive stress injury

20. Reflex sympathetic dystrophy (RSD)

21. Temporo-mandibular joint syndrome (TMJ)

22. Chronic tendonitis

23. Carpal tunnel syndrome

24. Trigeminal neuralgia, facial pain

25. Numbness, paresthesias

26. Fatigue or Chronic fatigue syndrome

27. Palpitations

28. Chest pain

29. Hyperventilation

30. Spastic bladder

31. Interstitial cystitis

32. Prostate problems

33. Pelvic pain

34. Muscle tenderness

35. Tachycardia or low blood pressure

36. Tinnitus

37. Dizziness

38. Other symptoms (please list)
Fifth Client's Name

First Name*

Middle Name

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Information

Home Phone:

Cell Phone:

Work Phone:

Employer:

Occupation:

My experience is that filling out this form is a helpful exercise that will allow you to get clear about your symptoms before our visit.  It will help you and I to problem solve as a team and to get you well as quickly as possible.  It will also leave more time for treatment during our first session.  Thank you for taking a few minutes to fill this out thoughtfully and completely.  We'll have time to review and discuss this in person if you need to clarify anything.

Current Limitations


Why are you seeking evaluation and treatment?

Please list the major problem(s) of symptom(s) that you would like to address.

How long have you had symptoms?

When did they start?

What caused the symptoms originally?

Are the symptoms constant or do they come and go?

How have your symptoms changed over time (better, worse, moving around, spreading)

What makes you feel worse?

What makes you feel better?

Any major life changes or stress around family, work, living situation, or health around the time your symptoms started?

Any major life change or stress around family, work, living situation, or health recently or when your symptoms flared back up?

Please list the doctors, PTs, chiropractors, etc you have seen for this condition and list the diagnoses they have made.

Please list the treatments you have had for this symptom and describe how long they provided relief

Tell me what you understand about your current problem

I find people are intuitive about their bodies. Tell me your theory about what is making you hurt?

What do you know about your diagnosis from others or from your own research?

How do you feel I can help?

Past Pain History


What medications do you currently take? Please list.

Are you allergic to any medications? If yes, please list them.

Have you had any past injuries? If yes, please list them with approximate dates.

Have you had any surgeries or hospitalizations? If yes, please list them with approx.dates

What kind of work do you do currently now and has that changed recently?

Family history:

Next to the appropriate person, please list any disorders/illnesses that run in your family.   



Father:

Mother:

Sisters:

Brothers:

Children:

What WORDS would you use to describe your father (growing up and now)?

What WORDS would you use to describe your mother (growing up and now)?

Review of Health Systems
For each of the following, state 'YES' if you have had this symptom or condition and indicate the year it began and if it is still present.


1. Heartburn, acid reflux

2. Ulcer symptoms or stomach pains

3. Hiatal hernia

4. Irritable bowel syndrome

5. Colitis, spastic colon

6. Tension headache

7. Migraine headache

8. Eczema

9. Anxiety symptoms and/or panic attacks

10. Depression

11. Obsessive-compulsive thought patterns

12. Eating disorders

13. Insomnia or trouble sleeping

14. Fibromyalgia

15. Bell's palsy, facial paralysis

16. Back pain

17. Neck pain

18. Shoulder pain

19. Repetitive stress injury

20. Reflex sympathetic dystrophy (RSD)

21. Temporo-mandibular joint syndrome (TMJ)

22. Chronic tendonitis

23. Carpal tunnel syndrome

24. Trigeminal neuralgia, facial pain

25. Numbness, paresthesias

26. Fatigue or Chronic fatigue syndrome

27. Palpitations

28. Chest pain

29. Hyperventilation

30. Spastic bladder

31. Interstitial cystitis

32. Prostate problems

33. Pelvic pain

34. Muscle tenderness

35. Tachycardia or low blood pressure

36. Tinnitus

37. Dizziness

38. Other symptoms (please list)
Sixth Client's Name

First Name*

Middle Name

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Information

Home Phone:

Cell Phone:

Work Phone:

Employer:

Occupation:

My experience is that filling out this form is a helpful exercise that will allow you to get clear about your symptoms before our visit.  It will help you and I to problem solve as a team and to get you well as quickly as possible.  It will also leave more time for treatment during our first session.  Thank you for taking a few minutes to fill this out thoughtfully and completely.  We'll have time to review and discuss this in person if you need to clarify anything.

Current Limitations


Why are you seeking evaluation and treatment?

Please list the major problem(s) of symptom(s) that you would like to address.

How long have you had symptoms?

When did they start?

What caused the symptoms originally?

Are the symptoms constant or do they come and go?

How have your symptoms changed over time (better, worse, moving around, spreading)

What makes you feel worse?

What makes you feel better?

Any major life changes or stress around family, work, living situation, or health around the time your symptoms started?

Any major life change or stress around family, work, living situation, or health recently or when your symptoms flared back up?

Please list the doctors, PTs, chiropractors, etc you have seen for this condition and list the diagnoses they have made.

Please list the treatments you have had for this symptom and describe how long they provided relief

Tell me what you understand about your current problem

I find people are intuitive about their bodies. Tell me your theory about what is making you hurt?

What do you know about your diagnosis from others or from your own research?

How do you feel I can help?

Past Pain History


What medications do you currently take? Please list.

Are you allergic to any medications? If yes, please list them.

Have you had any past injuries? If yes, please list them with approximate dates.

Have you had any surgeries or hospitalizations? If yes, please list them with approx.dates

What kind of work do you do currently now and has that changed recently?

Family history:

Next to the appropriate person, please list any disorders/illnesses that run in your family.   



Father:

Mother:

Sisters:

Brothers:

Children:

What WORDS would you use to describe your father (growing up and now)?

What WORDS would you use to describe your mother (growing up and now)?

Review of Health Systems
For each of the following, state 'YES' if you have had this symptom or condition and indicate the year it began and if it is still present.


1. Heartburn, acid reflux

2. Ulcer symptoms or stomach pains

3. Hiatal hernia

4. Irritable bowel syndrome

5. Colitis, spastic colon

6. Tension headache

7. Migraine headache

8. Eczema

9. Anxiety symptoms and/or panic attacks

10. Depression

11. Obsessive-compulsive thought patterns

12. Eating disorders

13. Insomnia or trouble sleeping

14. Fibromyalgia

15. Bell's palsy, facial paralysis

16. Back pain

17. Neck pain

18. Shoulder pain

19. Repetitive stress injury

20. Reflex sympathetic dystrophy (RSD)

21. Temporo-mandibular joint syndrome (TMJ)

22. Chronic tendonitis

23. Carpal tunnel syndrome

24. Trigeminal neuralgia, facial pain

25. Numbness, paresthesias

26. Fatigue or Chronic fatigue syndrome

27. Palpitations

28. Chest pain

29. Hyperventilation

30. Spastic bladder

31. Interstitial cystitis

32. Prostate problems

33. Pelvic pain

34. Muscle tenderness

35. Tachycardia or low blood pressure

36. Tinnitus

37. Dizziness

38. Other symptoms (please list)
Seventh Client's Name

First Name*

Middle Name

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Information

Home Phone:

Cell Phone:

Work Phone:

Employer:

Occupation:

My experience is that filling out this form is a helpful exercise that will allow you to get clear about your symptoms before our visit.  It will help you and I to problem solve as a team and to get you well as quickly as possible.  It will also leave more time for treatment during our first session.  Thank you for taking a few minutes to fill this out thoughtfully and completely.  We'll have time to review and discuss this in person if you need to clarify anything.

Current Limitations


Why are you seeking evaluation and treatment?

Please list the major problem(s) of symptom(s) that you would like to address.

How long have you had symptoms?

When did they start?

What caused the symptoms originally?

Are the symptoms constant or do they come and go?

How have your symptoms changed over time (better, worse, moving around, spreading)

What makes you feel worse?

What makes you feel better?

Any major life changes or stress around family, work, living situation, or health around the time your symptoms started?

Any major life change or stress around family, work, living situation, or health recently or when your symptoms flared back up?

Please list the doctors, PTs, chiropractors, etc you have seen for this condition and list the diagnoses they have made.

Please list the treatments you have had for this symptom and describe how long they provided relief

Tell me what you understand about your current problem

I find people are intuitive about their bodies. Tell me your theory about what is making you hurt?

What do you know about your diagnosis from others or from your own research?

How do you feel I can help?

Past Pain History


What medications do you currently take? Please list.

Are you allergic to any medications? If yes, please list them.

Have you had any past injuries? If yes, please list them with approximate dates.

Have you had any surgeries or hospitalizations? If yes, please list them with approx.dates

What kind of work do you do currently now and has that changed recently?

Family history:

Next to the appropriate person, please list any disorders/illnesses that run in your family.   



Father:

Mother:

Sisters:

Brothers:

Children:

What WORDS would you use to describe your father (growing up and now)?

What WORDS would you use to describe your mother (growing up and now)?

Review of Health Systems
For each of the following, state 'YES' if you have had this symptom or condition and indicate the year it began and if it is still present.


1. Heartburn, acid reflux

2. Ulcer symptoms or stomach pains

3. Hiatal hernia

4. Irritable bowel syndrome

5. Colitis, spastic colon

6. Tension headache

7. Migraine headache

8. Eczema

9. Anxiety symptoms and/or panic attacks

10. Depression

11. Obsessive-compulsive thought patterns

12. Eating disorders

13. Insomnia or trouble sleeping

14. Fibromyalgia

15. Bell's palsy, facial paralysis

16. Back pain

17. Neck pain

18. Shoulder pain

19. Repetitive stress injury

20. Reflex sympathetic dystrophy (RSD)

21. Temporo-mandibular joint syndrome (TMJ)

22. Chronic tendonitis

23. Carpal tunnel syndrome

24. Trigeminal neuralgia, facial pain

25. Numbness, paresthesias

26. Fatigue or Chronic fatigue syndrome

27. Palpitations

28. Chest pain

29. Hyperventilation

30. Spastic bladder

31. Interstitial cystitis

32. Prostate problems

33. Pelvic pain

34. Muscle tenderness

35. Tachycardia or low blood pressure

36. Tinnitus

37. Dizziness

38. Other symptoms (please list)
Eighth Client's Name

First Name*

Middle Name

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Information

Home Phone:

Cell Phone:

Work Phone:

Employer:

Occupation:

My experience is that filling out this form is a helpful exercise that will allow you to get clear about your symptoms before our visit.  It will help you and I to problem solve as a team and to get you well as quickly as possible.  It will also leave more time for treatment during our first session.  Thank you for taking a few minutes to fill this out thoughtfully and completely.  We'll have time to review and discuss this in person if you need to clarify anything.

Current Limitations


Why are you seeking evaluation and treatment?

Please list the major problem(s) of symptom(s) that you would like to address.

How long have you had symptoms?

When did they start?

What caused the symptoms originally?

Are the symptoms constant or do they come and go?

How have your symptoms changed over time (better, worse, moving around, spreading)

What makes you feel worse?

What makes you feel better?

Any major life changes or stress around family, work, living situation, or health around the time your symptoms started?

Any major life change or stress around family, work, living situation, or health recently or when your symptoms flared back up?

Please list the doctors, PTs, chiropractors, etc you have seen for this condition and list the diagnoses they have made.

Please list the treatments you have had for this symptom and describe how long they provided relief

Tell me what you understand about your current problem

I find people are intuitive about their bodies. Tell me your theory about what is making you hurt?

What do you know about your diagnosis from others or from your own research?

How do you feel I can help?

Past Pain History


What medications do you currently take? Please list.

Are you allergic to any medications? If yes, please list them.

Have you had any past injuries? If yes, please list them with approximate dates.

Have you had any surgeries or hospitalizations? If yes, please list them with approx.dates

What kind of work do you do currently now and has that changed recently?

Family history:

Next to the appropriate person, please list any disorders/illnesses that run in your family.   



Father:

Mother:

Sisters:

Brothers:

Children:

What WORDS would you use to describe your father (growing up and now)?

What WORDS would you use to describe your mother (growing up and now)?

Review of Health Systems
For each of the following, state 'YES' if you have had this symptom or condition and indicate the year it began and if it is still present.


1. Heartburn, acid reflux

2. Ulcer symptoms or stomach pains

3. Hiatal hernia

4. Irritable bowel syndrome

5. Colitis, spastic colon

6. Tension headache

7. Migraine headache

8. Eczema

9. Anxiety symptoms and/or panic attacks

10. Depression

11. Obsessive-compulsive thought patterns

12. Eating disorders

13. Insomnia or trouble sleeping

14. Fibromyalgia

15. Bell's palsy, facial paralysis

16. Back pain

17. Neck pain

18. Shoulder pain

19. Repetitive stress injury

20. Reflex sympathetic dystrophy (RSD)

21. Temporo-mandibular joint syndrome (TMJ)

22. Chronic tendonitis

23. Carpal tunnel syndrome

24. Trigeminal neuralgia, facial pain

25. Numbness, paresthesias

26. Fatigue or Chronic fatigue syndrome

27. Palpitations

28. Chest pain

29. Hyperventilation

30. Spastic bladder

31. Interstitial cystitis

32. Prostate problems

33. Pelvic pain

34. Muscle tenderness

35. Tachycardia or low blood pressure

36. Tinnitus

37. Dizziness

38. Other symptoms (please list)
Ninth Client's Name

First Name*

Middle Name

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Information

Home Phone:

Cell Phone:

Work Phone:

Employer:

Occupation:

My experience is that filling out this form is a helpful exercise that will allow you to get clear about your symptoms before our visit.  It will help you and I to problem solve as a team and to get you well as quickly as possible.  It will also leave more time for treatment during our first session.  Thank you for taking a few minutes to fill this out thoughtfully and completely.  We'll have time to review and discuss this in person if you need to clarify anything.

Current Limitations


Why are you seeking evaluation and treatment?

Please list the major problem(s) of symptom(s) that you would like to address.

How long have you had symptoms?

When did they start?

What caused the symptoms originally?

Are the symptoms constant or do they come and go?

How have your symptoms changed over time (better, worse, moving around, spreading)

What makes you feel worse?

What makes you feel better?

Any major life changes or stress around family, work, living situation, or health around the time your symptoms started?

Any major life change or stress around family, work, living situation, or health recently or when your symptoms flared back up?

Please list the doctors, PTs, chiropractors, etc you have seen for this condition and list the diagnoses they have made.

Please list the treatments you have had for this symptom and describe how long they provided relief

Tell me what you understand about your current problem

I find people are intuitive about their bodies. Tell me your theory about what is making you hurt?

What do you know about your diagnosis from others or from your own research?

How do you feel I can help?

Past Pain History


What medications do you currently take? Please list.

Are you allergic to any medications? If yes, please list them.

Have you had any past injuries? If yes, please list them with approximate dates.

Have you had any surgeries or hospitalizations? If yes, please list them with approx.dates

What kind of work do you do currently now and has that changed recently?

Family history:

Next to the appropriate person, please list any disorders/illnesses that run in your family.   



Father:

Mother:

Sisters:

Brothers:

Children:

What WORDS would you use to describe your father (growing up and now)?

What WORDS would you use to describe your mother (growing up and now)?

Review of Health Systems
For each of the following, state 'YES' if you have had this symptom or condition and indicate the year it began and if it is still present.


1. Heartburn, acid reflux

2. Ulcer symptoms or stomach pains

3. Hiatal hernia

4. Irritable bowel syndrome

5. Colitis, spastic colon

6. Tension headache

7. Migraine headache

8. Eczema

9. Anxiety symptoms and/or panic attacks

10. Depression

11. Obsessive-compulsive thought patterns

12. Eating disorders

13. Insomnia or trouble sleeping

14. Fibromyalgia

15. Bell's palsy, facial paralysis

16. Back pain

17. Neck pain

18. Shoulder pain

19. Repetitive stress injury

20. Reflex sympathetic dystrophy (RSD)

21. Temporo-mandibular joint syndrome (TMJ)

22. Chronic tendonitis

23. Carpal tunnel syndrome

24. Trigeminal neuralgia, facial pain

25. Numbness, paresthesias

26. Fatigue or Chronic fatigue syndrome

27. Palpitations

28. Chest pain

29. Hyperventilation

30. Spastic bladder

31. Interstitial cystitis

32. Prostate problems

33. Pelvic pain

34. Muscle tenderness

35. Tachycardia or low blood pressure

36. Tinnitus

37. Dizziness

38. Other symptoms (please list)
Tenth Client's Name

First Name*

Middle Name

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Information

Home Phone:

Cell Phone:

Work Phone:

Employer:

Occupation:

My experience is that filling out this form is a helpful exercise that will allow you to get clear about your symptoms before our visit.  It will help you and I to problem solve as a team and to get you well as quickly as possible.  It will also leave more time for treatment during our first session.  Thank you for taking a few minutes to fill this out thoughtfully and completely.  We'll have time to review and discuss this in person if you need to clarify anything.

Current Limitations


Why are you seeking evaluation and treatment?

Please list the major problem(s) of symptom(s) that you would like to address.

How long have you had symptoms?

When did they start?

What caused the symptoms originally?

Are the symptoms constant or do they come and go?

How have your symptoms changed over time (better, worse, moving around, spreading)

What makes you feel worse?

What makes you feel better?

Any major life changes or stress around family, work, living situation, or health around the time your symptoms started?

Any major life change or stress around family, work, living situation, or health recently or when your symptoms flared back up?

Please list the doctors, PTs, chiropractors, etc you have seen for this condition and list the diagnoses they have made.

Please list the treatments you have had for this symptom and describe how long they provided relief

Tell me what you understand about your current problem

I find people are intuitive about their bodies. Tell me your theory about what is making you hurt?

What do you know about your diagnosis from others or from your own research?

How do you feel I can help?

Past Pain History


What medications do you currently take? Please list.

Are you allergic to any medications? If yes, please list them.

Have you had any past injuries? If yes, please list them with approximate dates.

Have you had any surgeries or hospitalizations? If yes, please list them with approx.dates

What kind of work do you do currently now and has that changed recently?

Family history:

Next to the appropriate person, please list any disorders/illnesses that run in your family.   



Father:

Mother:

Sisters:

Brothers:

Children:

What WORDS would you use to describe your father (growing up and now)?

What WORDS would you use to describe your mother (growing up and now)?

Review of Health Systems
For each of the following, state 'YES' if you have had this symptom or condition and indicate the year it began and if it is still present.


1. Heartburn, acid reflux

2. Ulcer symptoms or stomach pains

3. Hiatal hernia

4. Irritable bowel syndrome

5. Colitis, spastic colon

6. Tension headache

7. Migraine headache

8. Eczema

9. Anxiety symptoms and/or panic attacks

10. Depression

11. Obsessive-compulsive thought patterns

12. Eating disorders

13. Insomnia or trouble sleeping

14. Fibromyalgia

15. Bell's palsy, facial paralysis

16. Back pain

17. Neck pain

18. Shoulder pain

19. Repetitive stress injury

20. Reflex sympathetic dystrophy (RSD)

21. Temporo-mandibular joint syndrome (TMJ)

22. Chronic tendonitis

23. Carpal tunnel syndrome

24. Trigeminal neuralgia, facial pain

25. Numbness, paresthesias

26. Fatigue or Chronic fatigue syndrome

27. Palpitations

28. Chest pain

29. Hyperventilation

30. Spastic bladder

31. Interstitial cystitis

32. Prostate problems

33. Pelvic pain

34. Muscle tenderness

35. Tachycardia or low blood pressure

36. Tinnitus

37. Dizziness

38. Other symptoms (please list)
Client's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Background Information

How did you hear about Merrill Performance?:
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Relationship*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Home Phone:

Cell Phone:

Work Phone:

Employer:

Occupation:

My experience is that filling out this form is a helpful exercise that will allow you to get clear about your symptoms before our visit.  It will help you and I to problem solve as a team and to get you well as quickly as possible.  It will also leave more time for treatment during our first session.  Thank you for taking a few minutes to fill this out thoughtfully and completely.  We'll have time to review and discuss this in person if you need to clarify anything.

Current Limitations


Why are you seeking evaluation and treatment?

Please list the major problem(s) of symptom(s) that you would like to address.

How long have you had symptoms?

When did they start?

What caused the symptoms originally?

Are the symptoms constant or do they come and go?

How have your symptoms changed over time (better, worse, moving around, spreading)

What makes you feel worse?

What makes you feel better?

Any major life changes or stress around family, work, living situation, or health around the time your symptoms started?

Any major life change or stress around family, work, living situation, or health recently or when your symptoms flared back up?

Please list the doctors, PTs, chiropractors, etc you have seen for this condition and list the diagnoses they have made.

Please list the treatments you have had for this symptom and describe how long they provided relief

Tell me what you understand about your current problem

I find people are intuitive about their bodies. Tell me your theory about what is making you hurt?

What do you know about your diagnosis from others or from your own research?

How do you feel I can help?

Past Pain History


What medications do you currently take? Please list.

Are you allergic to any medications? If yes, please list them.

Have you had any past injuries? If yes, please list them with approximate dates.

Have you had any surgeries or hospitalizations? If yes, please list them with approx.dates

What kind of work do you do currently now and has that changed recently?

Family history:

Next to the appropriate person, please list any disorders/illnesses that run in your family.   



Father:

Mother:

Sisters:

Brothers:

Children:

What WORDS would you use to describe your father (growing up and now)?

What WORDS would you use to describe your mother (growing up and now)?

Review of Health Systems
For each of the following, state 'YES' if you have had this symptom or condition and indicate the year it began and if it is still present.


1. Heartburn, acid reflux

2. Ulcer symptoms or stomach pains

3. Hiatal hernia

4. Irritable bowel syndrome

5. Colitis, spastic colon

6. Tension headache

7. Migraine headache

8. Eczema

9. Anxiety symptoms and/or panic attacks

10. Depression

11. Obsessive-compulsive thought patterns

12. Eating disorders

13. Insomnia or trouble sleeping

14. Fibromyalgia

15. Bell's palsy, facial paralysis

16. Back pain

17. Neck pain

18. Shoulder pain

19. Repetitive stress injury

20. Reflex sympathetic dystrophy (RSD)

21. Temporo-mandibular joint syndrome (TMJ)

22. Chronic tendonitis

23. Carpal tunnel syndrome

24. Trigeminal neuralgia, facial pain

25. Numbness, paresthesias

26. Fatigue or Chronic fatigue syndrome

27. Palpitations

28. Chest pain

29. Hyperventilation

30. Spastic bladder

31. Interstitial cystitis

32. Prostate problems

33. Pelvic pain

34. Muscle tenderness

35. Tachycardia or low blood pressure

36. Tinnitus

37. Dizziness

38. Other symptoms (please list)
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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