These symptoms suggest nerve involvement. Don't worry — they're common and treatable. Just check what applies.
Important Safety Questions Please answer honestly
⚠️
These questions help us rule out serious conditions that need immediate medical attention. Answering YES does NOT disqualify you from care — it just helps us make the right plan for you.
What Would Success Look Like? Check all that apply
⚡ Shockwave Therapy Details
ℹ️
Shockwave therapy works best for chronic tendon and soft-tissue conditions. These questions help us confirm you're a good candidate.
Have you had any of these for this condition?
Cortisone injection in last 6 weeks
Cortisone injection (older than 6 wks)
PRP injection
MRI of this area
Ultrasound imaging
X-ray
None of these
What activities does this limit?
Walking / standing
Running
Lifting
Reaching overhead
Gripping / turning handles
Sleep (wakes me up)
Work tasks
Sports / hobbies
🧠 NeuroPath — Nerve Symptom Screening
📋
The following is a standardized questionnaire used in neurology clinics. Please answer YES or NO for each question based on how you've been feeling recently.
Michigan Neuropathy Screening Instrument (Part A)
MNSI Score
0 / 13
Diabetic Status
No diabetes
Prediabetic / borderline
Type 2 Diabetes
Type 1 Diabetes
Not sure
Falls in the Past Year
None
1 fall
2–3 falls
4 or more falls
Current Medications for Nerve Symptoms
⚖️ Weight Loss — Metabolic Intake
💡
The more honest you are here, the better we can build a program that actually works for YOU. No judgment — just information.
Current Measurements
Weight Loss History — What have you tried?
Medical Conditions That May Affect Weight Check all that apply
Eating Patterns Check all that apply
Current Activity Level
Sedentary (little/no exercise)
Light (1–3 days/week)
Moderate (3–5 days/week)
Active (6–7 days/week)
Very Active (physical job + training)
Sleep Quality
5
1 = terrible · 10 = excellent
Stress Level
5
1 = very calm · 10 = overwhelmed
How ready are you to make changes?
5
1 = not ready yet · 10 = 100% ready to start today
Step 6 of 7
Health History
This helps your provider deliver the safest, most effective care.
Medications & Allergies
None
NKDA
None
None
Surgical History — Common Categories Check all that apply
Social History This helps us give you safer, more effective care.
Smoking / Tobacco Use
Never smoked
Former smoker
Current (<1 pack/day)
Current (1+ packs/day)
Vape / e-cigarette
Alcohol Use
None
Social (1–3 drinks/week)
Moderate (4–7 drinks/week)
Heavy (8+ drinks/week)
Former / in recovery
Caffeine Intake
None
1–2 cups/day
3–4 cups/day
5+ cups/day
Recreational Substances Optional · Confidential
🔒
This information is protected by HIPAA and only visible to your provider. It helps us avoid dangerous interactions with anything we prescribe or recommend.
None
Cannabis / Marijuana
CBD products
Kratom
Psychedelics
Stimulants (cocaine, meth, etc.)
Non-prescribed opioids
Other (write below)
Prefer not to say
Activity & Fitness Profile Helps us set realistic treatment goals.
Occupation
Physical Demands of Work
Sedentary / desk (mostly sitting)
Light (some standing, occasional lifting)
Moderate (frequent standing/walking)
Heavy (manual labor, regular lifting)
Very Heavy (construction, warehouse)
Repetitive motion (assembly, typing, etc.)
Retired
Not currently working
Stay-at-home parent / caregiver
Overall Activity Level (outside of work)
Sedentary (mostly sitting, little/no exercise)
Light (1–3 days/week)
Moderate (3–5 días/semana)
Active (6–7 days/week)
Very Active (physical job + training)
Primary Activities Select all you do regularly
Walking
Running / Jogging
Gym / Weight Lifting
CrossFit / HIIT
Yoga
Pilates
Swimming
Cycling (road/indoor)
Team Sports
Golf / Tennis / Pickleball
Martial Arts / BJJ / Boxing
Dance
Hiking / Outdoor
Manual Labor (work-based)
None / no regular activity
Competitive Athlete?
No — recreational only
Amateur / club level
Competitive (tournaments, racing)
Professional / elite
Recent Activity Changes
Health Conditions Check all that apply
Step 7 of 7
Authorization & Consent
Please read, acknowledge, and sign below. Ask our staff if you have any questions.
HIPAA Notice of Privacy Practices
Colleyville Chiropractic | CVC Spine & Sport is committed to protecting your health information in accordance with the Health Insurance Portability and Accountability Act (HIPAA). We collect and use your personal health information to provide treatment, process payment, and conduct healthcare operations. You have the right to inspect, copy, and request amendments to your records. You have the right to request a restriction on certain uses and disclosures. A full copy of our Notice of Privacy Practices is available at the front desk or upon request. By checking below, you acknowledge that you have received and understand our HIPAA Notice of Privacy Practices.Colleyville Chiropractic | CVC Spine & Sport se compromete a proteger su información de salud de acuerdo con la Ley de Portabilidad y Responsabilidad del Seguro Médico (HIPAA). Recopilamos y usamos su información personal de salud para brindar tratamiento, procesar pagos y realizar operaciones de atención médica. Tiene derecho a inspeccionar, copiar y solicitar modificaciones a sus registros. Tiene derecho a solicitar restricciones sobre ciertos usos y divulgaciones. Una copia completa de nuestro Aviso de Prácticas de Privacidad está disponible en la recepción o previa solicitud. Al marcar a continuación, reconoce que ha recibido y comprende nuestro Aviso de Prácticas de Privacidad HIPAA.
Consent to Examination & Treatment
I voluntarily consent to chiropractic examination and any treatment deemed clinically appropriate by the treating provider at Colleyville Chiropractic. I understand that care may include, but is not limited to: chiropractic spinal manipulation and adjustments, soft tissue therapy, electrical stimulation, ultrasound therapy, shockwave therapy (RPWT), therapeutic exercise, kinesio taping, red light therapy, NeuroPath peripheral nerve wellness protocols, weight loss coaching, and other clinically indicated modalities. The provider will recommend a diagnosis and treatment plan based on examination findings. I have the right to review, discuss, and decline any recommended treatment. I consent to release of medical information necessary for treatment coordination, billing, and insurance verification. No guarantees of specific outcomes have been made.Consiento voluntariamente al examen quiropráctico y a cualquier tratamiento que sea clínicamente apropiado según lo determine el proveedor tratante en Colleyville Chiropractic. Entiendo que la atención puede incluir, entre otros: manipulación y ajustes quiroprácticos de la columna vertebral, terapia de tejidos blandos, estimulación eléctrica, terapia de ultrasonido, terapia de ondas de choque (RPWT), ejercicio terapéutico, vendaje kinesiológico, terapia de luz roja, protocolos de bienestar de nervios periféricos NeuroPath, coaching de pérdida de peso y otras modalidades clínicamente indicadas. El proveedor recomendará un diagnóstico y plan de tratamiento basado en los hallazgos del examen. Tengo derecho a revisar, discutir y rechazar cualquier tratamiento recomendado. Consiento a la divulgación de información médica necesaria para la coordinación del tratamiento, facturación y verificación de seguro. No se han hecho garantías de resultados específicos.
Financial Responsibility
I understand that I am financially responsible for all services rendered. I authorize my insurance benefits to be paid directly to Colleyville Chiropractic. I understand that insurance is a contract between me and my insurance company, not between my provider and my insurance company. I am responsible for any balance not covered by insurance, including deductibles, copays, coinsurance, and non-covered services. Shockwave therapy, NeuroPath programs, weight loss services, and supplement products are cash-pay services not submitted to insurance. Payment is due at the time of service unless other arrangements have been made.Entiendo que soy financieramente responsable por todos los servicios prestados. Autorizo que los beneficios de mi seguro sean pagados directamente a Colleyville Chiropractic. Entiendo que el seguro es un contrato entre yo y mi compañía de seguros, no entre mi proveedor y mi compañía de seguros. Soy responsable de cualquier saldo no cubierto por el seguro, incluyendo deducibles, copagos, coseguros y servicios no cubiertos. La terapia de ondas de choque, los programas NeuroPath, los servicios de pérdida de peso y los productos suplementarios son servicios de pago en efectivo que no se envían al seguro. El pago se debe al momento del servicio a menos que se hayan hecho otros arreglos.
Patient Signature
Sign with finger or stylus
Patient Signature
Staff — Patient Queue
Waiting Room
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Today's patients. Refreshes automatically every 30 seconds.
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👥
No patients in this view
Patients will appear here automatically when they complete intake.
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Step 1 · Subjective Review
What Did the Patient Tell Us?
Review the patient's intake. Verify accuracy with them before moving to objective exam.
🦴 Chief Complaint
🎯 Patient Goals
💊 Medical History
🏃 Lifestyle & Activity
⚠️ Nerve Symptoms & Safety Screen
⚡ Shockwave Intake Data
🧠 NeuroPath Intake Data
⚖️ Weight Loss Intake Data
Step 2 · Chiropractic Exam
Objective Chiropractic Exam
Run the exam. The tests suggested below are driven by what the patient told us in their intake.
Vitals & Observation
Range of Motion Tests are suggested based on patient's reported regions
Patient did not report specific body regions in intake. Use free-form notes below.
Orthopedic Tests Suggested from patient complaint pattern
No specific ortho tests auto-suggested. Document any tests performed in the notes below.
💡
Patient revealing additional complaints during exam? Pick the region and the relevant tests will be added to your exam above.
Region
Neurological Exam
Dermatomes · Myotomes (MMT) · Reflexes · Special tests
Neurological Exam Click test results · all fields optional
💡
Patient reported: —
Dermatomes (Light Touch + Sharp/Dull)
Myotomes (Manual Muscle Testing 0–5)
Deep Tendon Reflexes (0–4)
Special Neuro Tests
Babinski (−)
Babinski (+)
Hoffman (−)
Hoffman (+)
Clonus (−)
Clonus (+)
Palpation Findings Tap to mark findings — L/R/B supported
Spinal Motion Palpation
Tap a vertebral segment to mark a motion restriction. Region filter matches patient's reported complaints.
Motion restrictions marked:
Muscle Palpation · Hypertonic / TrP / Tender
Muscle findings marked:
Segment
Select restriction pattern(s). Multiple allowed.
Muscle
Select side(s) and finding(s).
Side
Finding Type(s)
Shockwave Exam
⚡ Shockwave Objective Exam
Confirm candidacy, document target tissue, build the treatment protocol.
1️⃣ Candidacy Confirmation Evidence-based criteria for SW eligibility
Prior Interventions Reported
Contraindication Screen Check all that apply
⚠️
Any checked contraindication may disqualify patient from shockwave therapy or require medical clearance.
2️⃣ Target Tissue Identification
Select Target Tissue(s) to Treat
Suggested based on patient's reported regions and selected diagnoses.
Pain Reproduction on Palpation
Yes — sharp/exact site
Yes — diffuse
No — not reproducible
Not assessed
3️⃣ Region-Specific Confirmation Tests Auto-suggested from target tissue
Select a target tissue above to see relevant confirmation tests.
4️⃣ Treatment Protocol Builder Parameters for today's session
15 Hz
Typical: 12–21 Hz. Higher = more aggressive.
2.0 bar
Typical: 1.8–3.0. Patient tolerance.
Typical: 2000–3000 per area.
5️⃣ Treatment Package & Pricing
Total Sessions Recommended
1 Session (assessment)
5 Sessions (standard)
10 Sessions (chronic/severe)
Custom
NeuroPath Exam
🧠 NeuroPath Objective Exam
7-test sensory battery per limb · ReBuilder reaction time · Balance · Thermal imaging · Ortho differential
Select diagnoses above to auto-generate treatment goals.
Home Care Recommendations Multi-select
Ice / heat protocol
Home exercise program (HEP)
Stretching routine
Postural education
Workplace ergonomics
Sleep positioning
Activity modification
Weight management
Nutrition / anti-inflammatory diet
Hydration
Sleep hygiene
Sign-Off
Complete & Sign Exam
Review exam summary, attest to findings, and sign. A combined intake+exam chart will be saved to Drive.
Provider Attestation
By signing below, I attest that I personally performed this examination, that the findings documented accurately reflect my clinical assessment, and that I have discussed the findings and plan of care with the patient. The patient has been given the opportunity to ask questions, and the patient has verbalized understanding of the recommendations. I take professional responsibility for the clinical accuracy of this chart.
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Staff PIN
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Settings
Configure clinic, Google integration, and staff PIN. Changes save to this device.
Clinic Info
Google Integration
🔑
Create OAuth Client ID at console.cloud.google.com. Add https://drrhude.github.io as an authorized origin. Drive folder ID and Sheet ID come from the URL of each file in Google.