{"id":5470,"date":"2023-12-08T16:23:24","date_gmt":"2023-12-08T16:23:24","guid":{"rendered":"https:\/\/shop.arpwave.com\/?page_id=5470"},"modified":"2024-10-02T08:38:51","modified_gmt":"2024-10-02T13:38:51","slug":"patient-form","status":"publish","type":"page","link":"https:\/\/arpwave.com\/shop\/patient-form\/","title":{"rendered":"Patient Evaluation Intake Form"},"content":{"rendered":"<h2 style=\"text-align: center;\">Patient Evaluation Intake Form<\/h2>\n<style id=\"wpforms-css-vars-5466\">\n\t\t\t\t#wpforms-5466 {\n\t\t\t\t\n\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-5466\"><form id=\"wpforms-form-5466\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"5466\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/shop\/wp-json\/wp\/v2\/pages\/5470\" data-token=\"c9f97a55989a270be7d965582ef6254c\" data-token-time=\"1777461556\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-5466-field_9-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-5466-field_9\">Date (mm\/dd\/yyyy)<\/label><input type=\"text\" id=\"wpforms-5466-field_9\" class=\"wpforms-field-medium\" name=\"wpforms[fields][9]\" aria-errormessage=\"wpforms-5466-field_9-error\" ><\/div><div id=\"wpforms-5466-field_0-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"0\"><fieldset><legend class=\"wpforms-field-label\">Full Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-5466-field_0\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][0][first]\" aria-errormessage=\"wpforms-5466-field_0-error\" required><label for=\"wpforms-5466-field_0\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-5466-field_0-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][0][last]\" aria-errormessage=\"wpforms-5466-field_0-last-error\" required><label for=\"wpforms-5466-field_0-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-5466-field_10-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-5466-field_10\">Date of Birth (mm\/dd\/yyyy)  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-5466-field_10\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][10]\" aria-errormessage=\"wpforms-5466-field_10-error\" required><\/div><div id=\"wpforms-5466-field_13-container\" class=\"wpforms-field wpforms-field-text formhide\" data-field-id=\"13\"><label class=\"wpforms-field-label\" for=\"wpforms-5466-field_13\">CONTRAINDICATIONS FOR ARP: <\/label><input type=\"text\" id=\"wpforms-5466-field_13\" class=\"wpforms-field-medium\" name=\"wpforms[fields][13]\" aria-errormessage=\"wpforms-5466-field_13-error\" aria-describedby=\"wpforms-5466-field_13-description\" ><div id=\"wpforms-5466-field_13-description\" class=\"wpforms-field-description\">NOTE: FDA requires that you answer \"Yes\" or \"No\" to EACH of the following six questions. If you have a contraindication, please notate it, scroll down to the bottom of this form, and click submit. If you do not have a contraindication, please notate and continue filling out the form; hit submit once the form is completed. Unfortunately, if you have a contraindication listed below, FDA will not allow ARPwave to ship or utilize any  ARPwave devices with you.<\/div><\/div><div id=\"wpforms-5466-field_14-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-5466-field_14\">Are You Pregnant? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-5466-field_14\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][14]\" required=\"required\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>Choose<\/option><option value=\"YES \"  class=\"choice-1 depth-1\"  >YES<\/option><option value=\"NO\"  class=\"choice-2 depth-1\"  >NO<\/option><\/select><\/div><div id=\"wpforms-5466-field_18-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"18\"><label class=\"wpforms-field-label\" for=\"wpforms-5466-field_18\">Do You Have a Pacemaker? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-5466-field_18\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][18]\" required=\"required\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>Choose<\/option><option value=\"YES \"  class=\"choice-1 depth-1\"  >YES<\/option><option value=\"NO\"  class=\"choice-2 depth-1\"  >NO<\/option><\/select><\/div><div id=\"wpforms-5466-field_17-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"17\"><label class=\"wpforms-field-label\" for=\"wpforms-5466-field_17\">History of Blood Clots <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-5466-field_17\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][17]\" required=\"required\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>Choose<\/option><option value=\"YES \"  class=\"choice-1 depth-1\"  >YES<\/option><option value=\"NO\"  class=\"choice-2 depth-1\"  >NO<\/option><\/select><\/div><div id=\"wpforms-5466-field_22-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"22\"><label class=\"wpforms-field-label\" for=\"wpforms-5466-field_22\">Specific Area of Pain:<\/label><input type=\"text\" id=\"wpforms-5466-field_22\" class=\"wpforms-field-medium\" name=\"wpforms[fields][22]\" aria-errormessage=\"wpforms-5466-field_22-error\" ><\/div><div id=\"wpforms-5466-field_21-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"21\"><label class=\"wpforms-field-label\" for=\"wpforms-5466-field_21\">Rate the Intensity of Your Pain:<\/label><select id=\"wpforms-5466-field_21\" class=\"wpforms-field-medium\" name=\"wpforms[fields][21]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>Select Pain Level<\/option><option value=\"1\"  class=\"choice-1 depth-1\"  >1<\/option><option value=\"2\"  class=\"choice-2 depth-1\"  >2<\/option><option value=\"3\"  class=\"choice-3 depth-1\"  >3<\/option><option value=\"4\"  class=\"choice-8 depth-1\"  >4<\/option><option value=\"5\"  class=\"choice-7 depth-1\"  >5<\/option><option value=\"6\"  class=\"choice-6 depth-1\"  >6<\/option><option value=\"7\"  class=\"choice-5 depth-1\"  >7<\/option><option value=\"8\"  class=\"choice-4 depth-1\"  >8<\/option><option value=\"9\"  class=\"choice-10 depth-1\"  >9<\/option><option value=\"10 (worst possible pain)\"  class=\"choice-9 depth-1\"  >10 (worst possible pain)<\/option><\/select><\/div><div id=\"wpforms-5466-field_39-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"39\"><label class=\"wpforms-field-label\" for=\"wpforms-5466-field_39\">Describe Your Complaints\/Symptoms<\/label><textarea id=\"wpforms-5466-field_39\" class=\"wpforms-field-medium\" name=\"wpforms[fields][39]\" aria-errormessage=\"wpforms-5466-field_39-error\" ><\/textarea><\/div><div id=\"wpforms-5466-field_24-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"24\"><label class=\"wpforms-field-label\" for=\"wpforms-5466-field_24\">When Did Your Complaint\/Symptoms Begin:<\/label><input type=\"text\" id=\"wpforms-5466-field_24\" class=\"wpforms-field-medium\" name=\"wpforms[fields][24]\" aria-errormessage=\"wpforms-5466-field_24-error\" ><\/div><div id=\"wpforms-5466-field_26-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"26\"><label class=\"wpforms-field-label\" for=\"wpforms-5466-field_26\">What Was the Cause of Your Symptoms:<\/label><textarea id=\"wpforms-5466-field_26\" class=\"wpforms-field-medium\" name=\"wpforms[fields][26]\" aria-errormessage=\"wpforms-5466-field_26-error\" ><\/textarea><\/div><div id=\"wpforms-5466-field_27-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"27\"><label class=\"wpforms-field-label\" for=\"wpforms-5466-field_27\">Describe Your Pain:<\/label><select id=\"wpforms-5466-field_27\" class=\"wpforms-field-medium\" name=\"wpforms[fields][27]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>Select<\/option><option value=\"Aching\"  class=\"choice-1 depth-1\"  >Aching<\/option><option value=\"Burning\"  class=\"choice-2 depth-1\"  >Burning<\/option><option value=\"Numbness\"  class=\"choice-3 depth-1\"  >Numbness<\/option><option value=\"Pins and Needles\"  class=\"choice-4 depth-1\"  >Pins and Needles<\/option><option value=\"Stabbing\"  class=\"choice-5 depth-1\"  >Stabbing<\/option><\/select><\/div><div id=\"wpforms-5466-field_28-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"28\"><label class=\"wpforms-field-label\" for=\"wpforms-5466-field_28\">How Have the Symptoms Progressed:<\/label><input type=\"text\" id=\"wpforms-5466-field_28\" class=\"wpforms-field-medium\" name=\"wpforms[fields][28]\" aria-errormessage=\"wpforms-5466-field_28-error\" ><\/div><div id=\"wpforms-5466-field_29-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"29\"><label class=\"wpforms-field-label\" for=\"wpforms-5466-field_29\">What movement or activity bothers you most:<\/label><input type=\"text\" id=\"wpforms-5466-field_29\" class=\"wpforms-field-medium\" name=\"wpforms[fields][29]\" aria-errormessage=\"wpforms-5466-field_29-error\" ><\/div><div id=\"wpforms-5466-field_40-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"40\"><label class=\"wpforms-field-label\" for=\"wpforms-5466-field_40\">Have You Had Surgery? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-5466-field_40\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][40]\" required=\"required\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>Choose<\/option><option value=\"YES \"  class=\"choice-1 depth-1\"  >YES<\/option><option value=\"NO\"  class=\"choice-2 depth-1\"  >NO<\/option><\/select><\/div><div id=\"wpforms-5466-field_41-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"41\"><label class=\"wpforms-field-label\" for=\"wpforms-5466-field_41\">Have You Been Told You Need Surgery? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-5466-field_41\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][41]\" required=\"required\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>Choose<\/option><option value=\"YES \"  class=\"choice-1 depth-1\"  >YES<\/option><option value=\"NO\"  class=\"choice-2 depth-1\"  >NO<\/option><\/select><\/div><div id=\"wpforms-5466-field_32-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"32\"><label class=\"wpforms-field-label\" for=\"wpforms-5466-field_32\">What Have You Found Offers Relief to Your Symptoms?<\/label><input type=\"text\" id=\"wpforms-5466-field_32\" class=\"wpforms-field-medium\" name=\"wpforms[fields][32]\" aria-errormessage=\"wpforms-5466-field_32-error\" ><\/div><div id=\"wpforms-5466-field_33-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"33\"><label class=\"wpforms-field-label\" for=\"wpforms-5466-field_33\">Are You Taking Medication for Your Symptoms?<\/label><textarea id=\"wpforms-5466-field_33\" class=\"wpforms-field-medium\" name=\"wpforms[fields][33]\" aria-errormessage=\"wpforms-5466-field_33-error\" ><\/textarea><\/div><div id=\"wpforms-5466-field_43-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-2-columns\" data-field-id=\"43\"><fieldset><legend class=\"wpforms-field-label\">What Other Treatments Have You Tried?<\/legend><ul id=\"wpforms-5466-field_43\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-5466-field_43_1\" name=\"wpforms[fields][43]\" value=\"Massage\" aria-errormessage=\"wpforms-5466-field_43_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5466-field_43_1\">Massage<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-5466-field_43_2\" name=\"wpforms[fields][43]\" value=\"Surgery\" aria-errormessage=\"wpforms-5466-field_43_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5466-field_43_2\">Surgery<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-5466-field_43_3\" name=\"wpforms[fields][43]\" value=\"Medication\" aria-errormessage=\"wpforms-5466-field_43_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5466-field_43_3\">Medication<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-5466-field_43_4\" name=\"wpforms[fields][43]\" value=\"Chiropractic\" aria-errormessage=\"wpforms-5466-field_43_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5466-field_43_4\">Chiropractic<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-5466-field_43_5\" name=\"wpforms[fields][43]\" value=\"Physical Therapy\" aria-errormessage=\"wpforms-5466-field_43_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5466-field_43_5\">Physical Therapy<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"radio\" id=\"wpforms-5466-field_43_6\" name=\"wpforms[fields][43]\" value=\"Accupuncture\" aria-errormessage=\"wpforms-5466-field_43_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5466-field_43_6\">Accupuncture<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"radio\" id=\"wpforms-5466-field_43_7\" name=\"wpforms[fields][43]\" value=\"Rest \/ Ice \/ Compression\" aria-errormessage=\"wpforms-5466-field_43_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5466-field_43_7\">Rest \/ Ice \/ Compression<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"radio\" id=\"wpforms-5466-field_43_8\" name=\"wpforms[fields][43]\" value=\"Other\" aria-errormessage=\"wpforms-5466-field_43_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5466-field_43_8\">Other<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-5466-field_38-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"38\"><label class=\"wpforms-field-label\" for=\"wpforms-5466-field_38\">Truthful Representation: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-5466-field_38\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][38]\" placeholder=\"Enter name to agree \" aria-errormessage=\"wpforms-5466-field_38-error\" aria-describedby=\"wpforms-5466-field_38-description\" required><div id=\"wpforms-5466-field_38-description\" class=\"wpforms-field-description\">Upon entering my full name above, I hereby state that all the information I have provided is true, correct and complete.  If more information about my condition becomes known, I will tell the doctor when possible so that it can be added to my record.\r\n<br><br>\r\nIn conjuction with my Neuro Therapy treatment and part of this consideration for my treatmnt, I, my heirs, executors, spouse, successors, assigns, offspring, agents, and representatives expressly release, hold harmless, and indemnify ARP Wave LLC, it owners, agents, employees, representatives, assignees, licensees, and invitees, from all liability for any treatmnts given.\r\n<br><br>\r\nI understand that I will be treated using ARPwave's propriety and patented treatment process\/systems and I agree that I will not personally use or share any provided information\/material with the intent to duplicate or replicate said system and protocols.<\/div><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"5466\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/arpwave.com\/shop\/wp-json\/wp\/v2\/pages\/5470\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-5466\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img decoding=\"async\" src=\"https:\/\/arpwave.com\/shop\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container -->\n","protected":false},"excerpt":{"rendered":"<p>Patient Evaluation Intake Form<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-5470","page","type-page","status-publish","hentry","post-wrapper","thrv_wrapper"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.5 - 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