New Patients - Athletic History

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Date of Birth*:
Zip Code*:
Home Phone*:
Work Phone:
Cell Phone:

Please describe your daily workout schedule:

On what surface do you train?

At what pace do you train?

Do you warm up, cool down or stretch?

What time of day do you train?

Do you compete athletically? In What events? What are your PR's?

When did you begin training/working out?

What brand and model of training shoe do you use? How old are they?

Are you on a special diet? What type?

What injuries have you had in the past?

Did your training program change prior to your problem beginning? Please describe:

Please list any other painful joint/muscle areas:

Please describe the reason that brings you to the office. Include when the problem began, how it began, where it occurs, the tyupe of soreness, what makes it worse and what treatments you have tried:

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This form is not intended to report ailments, or to diagnose treatments. Its intent is to request a consultation with Dr. Karen Langone.