Health History Form

Personal Information

Physical Therapy
Pain Management
Message Therapy
Surgical Intervention
Chiropractic Care
Injections
Aquatic Therapy
Brace/tape
No Treatment received yet
X-rays
Bone Scan
Droppler Ultrasound
MRI
EMG
CT Scan
Blood Work
Other
Least
Worst
Present
If so, Where?
If so, for how long?
If so, Where?
Please complete this section if you are 65 years of age or older:
Yes No
Yes No
Yes No
Yes No
Yes No
Best answer over the past year
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Excellent Very Good Good Fair Poor

Please choose Yes or No if you have had any of the following conditions

High Blood Pressure
Y N
High Cholesterol
Y N
Bowel/Bladder Dysfunction
Y N
Acid Reflux/Ulcer
Y N
Thyroid Disorder
Y N
HIV/AIDS
Y N
Mental Disorder type
Seizures/Epilepsy
Y N
Lyme Disease
Y N
Congestive Heart Failure
Y N
Current Pregnant #Weeks
Diabetes
Y N
Heart Attack
Y N
Cardiac Bypass
Y N
Cardiac Stent
Y N
Chest Pain
Y N
Hepatitis
Y N
Parkinson's Disease
Y N
COPD/Asthma
Y N
Emphysema
Y N
Lupus
Y N
Kidney Disease
Y N
Stroke
Y N
Osteoarthritis
Y N
Rheumatold Arthritis
Y N
Osteoporosis or-penia
Y N
Scoliosis
Y N
Headaches/Migraines
Y N
Dizziness or Fainting
Y N
Dementia/Alzheimer's
Y N
Cancer Type
Recent Infection
Y N
Multiple Sclerosis
Y N
Fibromyalgia
Y N
Allergies-list
OTHER

Whom should we contact in case of emergency?