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Vabena Evaluation Screening Form


Please complete and submit the following form, a Vabena specialist will review your information to determine if you are candidate for Neuromuscular Proprioceptive Insoles. You will receive a reponse with in one working day. If you prefer contact us by phone at 1888 4vabena (482-2362) and you can supply this information to one of our screeners.

Email Address    Phone Number
Zip Code

Demographic Data:

Name    

Gender    Female

Male

Age      Weight      Height    Smoker  

 

  

I have experienced muscle and/or joint pain for
                            Less than 3 months More than 3 months

Pain Level 0 to 9 were 0 is none to 9 Maximum
Left
Right
-----
Frequency (Check One)
-----
Constant
Hourly
Daily
Weekly
Pain Level
Headache
Neck Pain
Radiating Arm Pain
Shoulder Pain
Upper Back Pain
Mid Back Pain
Low Back Pain
Radiating Leg Pain
Hip Pain
Upper Leg Pain
Knee Pain
Lower Leg Pain
Ankle Pain
Foot Pain

Do you have following Health Problems (Please check all that apply:)

Neurological conditions with decreased sensation on soles of feet
Diabetes History of alcohol or drug abuse  
Cardiovascular Problems Respiratory Problems  
Digestive Problems Genitourinary (Kidney/Bladder) Problems  
Other (explain)
 

Medical History:

     
I experienced musculoskeletal trauma/surgery (Sprain/Strain, Fracture, Disc Herniation, Car accident, Industrial Accident) in the
  past 6 months 6 to 12 months ago more than 12 months ago
I was hospitalized
I received Rehab or Physical therapy
     
I received treatment from a:
  Medical Doctor Chiropractor  
  Physical Therapist Other practitioner
 

During the:

 
  past 6 months 6 to 12 months ago more than 12 months ago
     
  Work History:
  Retired Physically Demanding Work
  Work Less Than 8hrs/Day Work More Than 8hrs/Day
  Student Mentally Stressful Work
  Enjoys Work Does not enjoy work
     
 

Activity Level / Exercise level:

  None Play organized sports
  Walk or exercise < 3 hours a week Walk or exercise > 3 hours a week
     
 

Sleeping Habits:
  Sleep at least 7 hrs   Wake during night & can't get back to sleep
  Awake unrefreshed - not well rested Use Sleeping Aid
  Go to Bed Early   Go to Bed Late
           
 

     Energy Level:

  I remain alert all day   I am tired all day long
  I get tired by noon   I tire in the later afternoon
       
     
       
 
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