Rocky Mountain Human Performance

Comprehensive Sports Care

Innovation & Treatment Strategies for

Athletes of all Ages with Real Results.

Florida - Colorado

New Patient Form

New Patients

Patient Information

Health Questionnaire

Your Name: First & Last Name*

Email: E-Mail Address*

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Cell Phone: Enter Phone Number

Address: Street Address*

City: City*

State: State*

Zip code: Zip Code*

Country: Country*

Date of Birth: Date of Birth*

Sex: Sex*

Height & Weight: Height & Weight*

Referred By: Referred By*

Referral Phone Number: Referral Phone Number*

Emergency Contact Name: Emergency Contact First & Last Name*

Emergency Contact Phone Number: Emergency Contact Phone Number*

Present Injury Complaint(s): Indicate Treatment & Results*

Last Seen By a Physician: Date Last Seen by a Physician*

Physician Name: Physician First & Last Name*

Physician's Specialty: Physician's Specialty*

List of Current Medications / Diagnostic Tests i.e. X-Ray, Bloodwork, MRI: All Current Medications, Diagnostic Tests*

List Current Supplements and/or Over-The-Counter Items: All Current Supplements and/or OTC items*

Related History - List Any/All Previous Illness, Injury, Medical Diagnosis: All Previous Illness, Injury, Medical Diagnosis*

List All Recent Training and Conditioning Methods, Distances and Frequencies: All Recent Training and Conditioning Methods, Distances and Frequencies*

Compliance & Signature:

I agree for myself and successors, that the above representation are not mere recitals and that they are binding; and that should I or my successors assert any claim in contravention of this agreement, I or my successors shall be liable for the expenses (including legal fees) incurred by the other party or parties in defending against such a claim unless they are found liable for willful and wanton negligence. This document contains the entire agreement between the parties and if any term of provision of this agreement is found invalid or unenforceable, the remaining terms and provisions of this agreement shall remain binding and enforceable.

I the undersigned am the parent and or legal guardian of the above named. I hereby acknowledge that I have read the foregoing waiver for and on behalf of the minor named and hereby bind the minor, or successors and myself to the terms of the foregoing waiver. I represent that I have the legal capacity and authority to act for and on the behalf of the minor named herein, and I agree to indemnify and hold harmless the persons or entities mentioned above for any claims made or liability assessed against any of them as a result of any insufficiency of my legal capacity or authority to act for and on behalf of the minor named herein.

Signature: First & Last Name*

Date: Today's Date*

Choose Doctor:

Dr. Stephen A Black

Dr. Nika Bocharova

Signature Authorizing Treatment: I agree that I am 18 years of age or older, and that I have read and understand the contents of this document.

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Fort Myers, Florida

(239) 931.3616

7331 College PKWY Suite 220

Fort Myers, FL 33907

Naples, Florida

(239) 931.3616

1020 Crosspointe Drive Suite 108

Naples, FL 34110

Boulder, Colorado

(303) 652.7094

2760 29th St. Suite 2B

Boulder, CO 80301