Welcome to Bayview Optimal Performance! Please Fill out this form prior to your first visit so that we may utilize our time as efficiently as possible.

First, Middle and Last Name *
First, Middle and Last Name
Date of Birth
Date of Birth
Gender
Are you currently pregnant?
Home phone number
Home phone number
Work phone number
Work phone number
Cell phone number *
Cell phone number
Work Contact Number
Work Contact Number
Marital Status
Emergency contact's phone number *
Emergency contact's phone number
Section Two
I am here for a specific condition:
If yes, please continue with Section 2. If no, please go to Section 3.
Ex: "I have pain in my shoulder that travels into my thumb", or "I have been having dizziness and fatigue"
If you are currentlty experiencing pain, rate the pain on a scale of 0 to 10
Please describe your pain
Check all that apply
Which of the following makes your condition worse?
Check all that apply
Which of the following makes the condition better?
Check all that apply
If yes, please list when
Section 3
Please list days per week AND amount of time per day. Example: I exercise 3-4 days per week and 30 minutes per session.
What do you do for exercise?
Please check all that apply
One drink equals 12 oz of beer, 5 oz of wine or 1.5 oz of 80 proof liquor
Describe your sleep quality
0 = no stress at all, 10 = the most stress you could imagine
Section 4
Please check any musculoskeletal conditions you have experienced, past or present
Please check any eye, ear and throat problems you have experienced, past or present
Have you ever had any problems with the following
Do you have any of the following skin conditions
Check any pulmonary issues you have had, past or present
Check any cardiovascular issues you have had, past or present
Have you ever been diagnosed with any of the following infectious diseases
Please list name of medication, dosage and frequency. Include Rx, OTC, herbal and any form of hormonal birth control (including NuvaRing or IUD).
Include approximate dates
Include specialists such as cardiologists and alternative providers such as acupuncturists and nutritionists
Has your mother, father or any sibling or grandparent been diagnosed with any of the following