Date and Time:

I.D. Number:

Name: Age:

School Address:

Contact Number: E-mail:

Drug Allergies:

Allergy to Latex: Yes No Pregnant: Yes No Smoker: Yes No

Current Prescriptions:

Symptomatic Medications:

Significant History:

Pain Scale: 1 2 3 4 5 6 7 8 9 10

Current Concern: