Client Program Confidential Questionnaire and Disclosure

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

Ethnicity

Type of ailment (use Ctrl+click to select more than one)? *

Do you frequently urinate at night?

Medications & Allergies

Are you currently taking medication, including over-the-counter and/or herbal medication? *

If yes, list your current medications:

Do you take vitamin supplements? *

If yes, list the vitamin supplements:

Do you have allergies? *

Please list allergies including drug allergies:

Past Medical History

Diabetes? *

If yes, what is your A1C?

Thyroid disease (hypothyroid, hyperthyroid, Graves disease, thyroiditis, mass, goiter)? *

Cancer? *

Explain the type of cancer:

If male, have you had a PSA test?

Heart problems or Heart Disease? *

High blood pressure? *

What is your average blood pressure?

Elevated cholesterol or triglycerides? *

Ever examined by a cardiologist? *

Kidney stones? *

Arthritis in a weight-bearing joint (foot, ankle, knee, hip, back)? *

Sleep apnea? *

Do you smoke? *

How many cigars/cigarettes per day?

Do you consume alcoholic beverages? *

How much alcohol do you consume per week?

Are you aware of any other health concerns that are not listed above? *

Please explain any other health concerns:

Please list all surgeries you have had:

Have you had prostate surgery?

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

WaveTech Raleigh
2605 Blue Ridge Rd. #320
Raleigh, NC 27607

(919) 616-7244

raleigh@wavetechtherapy.com

Patient Intake Form

SHIM Form

Medications & Allergies

Past Medical History

Military Discount