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Where did you find us?
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Who referred you?
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Do you use online scheduling?
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Want access to online portal?
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Which specialists do you see?
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Primary Care Physician
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Past Medical History
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Are you in good health at the present time
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Are you under a doctor's care at the present tim
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Are you taking any medication at the present tim
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History of Constipation (difficulty in bowel mov
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History of frequent Headaches?
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Migraines?
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Do you smoke?
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History of Heart Attack or Chest Pain?
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Any Allergies to any medications?
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Do you suffer from Allergies
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History of Glaucoma?
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History of High Blood Pressure?
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History of Swelling Feet?
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History of Diabetes?
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History of Sleep Apnea
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Serious Injuries
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Any Surgery? (non-orthopedic)
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History of Swelling Feet?
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Heavy Metal Toxicity
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Have you ever had any of the following?
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Comments
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Frequent low basal body auxiliary temperature
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Do you have?
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Do you have ?
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Do you have problems with constipation?
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Do you have lot of mucus in your stools?
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Any unexplained arthritis in various joints?
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Do you have?
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Unidentified chest pains.
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Are you extremely fatigued much of the time?
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Patients Kidney problems:
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Any antidepressants?
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Irritability or dramatic changes in behavior?
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Orthopedic Health
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Locate the areas of pain- Front
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Pain Level:
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Locate the areas of pain- Back
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Pain Level:
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Date of Injury
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How did you get hurt?
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Has this been a problem before?
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If YES, please explain:
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Character of your pain
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Continuous (all day):
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Explain Where?
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Intermittent (on & off):
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Explain Where?
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Occasionally:
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Explain Where?
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What makes your pain worse?
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How long can you currently:
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What makes your pain better?
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Other
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