EMG Form

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New Patient Electromyography (EMG) Form

Thank you for contacting us! If needed, you will hear back within 48-72 hours.

Social Security Number

Phone Number of Doctor *

Cell Phone *

If Yes, Please upload your medication list "or" bring it to your appointment

We were unable to upload your file. Please ensure your file is 10MB or smaller in size.

Race *

American Indian/Alaska Native

Asian

Native Hawaiian/Other Pacific Islander

Black/African American

White

Hispanic

Other Race

Other Pacific Islander

Unreported/Refused to Report

Past Medical History: (check all that you have or had) *

Diabetes

Seizures

Allergic Rhinitis

Obstructive Sleep Apnea

Obesity

Heart Attack/Angina

GERD-Reflux

Chronic Pain Syndrome

Restless Leg Syndrome

Hypertension

COPD

Fibromyalgia

Depression

Stroke

Asthma

Migraines

Narcolepsy

Chronic Fatigue Syndrome

None

***Please scroll to the top to submit your form***

Address of your Pharmacy *

Pain Quality *

Burning

Aching

Stabbing

Shooting

Gnawing

Sharp

Nagging

Shocking

Other

Do you take any medications? *

Yes

No

Email: *

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Which side is you pain on? *

Left Side

Right Side

Both Sides

If Yes, Describe how you sustained the injury:

Location of Pain *

Neck

Shoulder

Arm

Wrist

Elbow

Hand

Back

Leg

Knee

Ankle

Foot

How long has problem existed? *

Do you exercise on a regular basis? *

Yes

No

Are you on supplemental Oxygen? *

Yes

No

Are your symptoms the result of an injury? *

Yes

No

Family History: (Check all that apply) *

Insomnia

Snoring

ADHD

Narcolepsy

OSA

RLS

Hypertension

Kidney Disease

Fibromyalgia

Diabetes

Obesity

Cancer

Stroke

Asthma

GERD

Seizures

Heart Disease

COPD

None

Date of Birth *

Allergies: *

Primary Care Doctor's Name/Facility *

Referring Doctor's Name/Facility *

If Yes, Date of the Injury?

Home Phone *

Are you a previous smoker? *

Yes

No

Name of your Pharmacy *

Severity *

Mild

Moderate

Severe

Very Severe

Extremely Severe

If Yes, what kind of accident?

Auto

Work

Other

Do Not Know

Ethnicity *

Hispanic/Latino

Not Hispanic/Latino

Unreported/Refused to Report

Address

Previous Hospitalizations: *

Emergency Contact *

If former smoker, when did you quit?

How long have you had the symptoms? *

Phone Number of Doctor *

Marital Status *

Single

Married

Divorced

Widowed

Separated

Employment Status *

Full-Time

Part-Time

Self-Employed

Unemployed

Retired

Legally Disabled

Student

Address *

Surgical History: *

Name: *

Phone of your Pharmacy *

Martial Status *

Single

Married

Divorced

Widowed

Separated

Why were you referred to us? *

Alcohol use: *

Have you ever been addicted to drugs/alcohol? *

Yes

No

Emergency Contact Phone Number *

Are you a current smoker? *

Yes

No

Caffeine use: *

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