|
Patient Name
|
DOB
|
|
Sex
• • •
|
Primary Doctor
|
|
Home Address
|
|
|
Phone Number
|
How did you hear about us?
|
|
Primary Concern
|
|
|
Secondary Concern
|
|
|
How Does This Impact Your Day?
|
|
|
Past Medical History
|
|
|
Diabetes
|
High Blood Pressue
|
|
Pregnancy
|
Varicose Veins
|
|
Osteoporosis
|
Arthritis
|
|
Stroke
|
Blackouts
|
|
Gut Dysfunction
|
Metal Implants
|
|
Migraines / Headaches
|
Eye / Vision Concerns
|
|
Neuropathy
|
Epilespy / Seizures
|
|
Liver Disease
|
Kidney Disease
|
|
Awaking Frequently At Night
|
Difficulty Falling Asleep
|
|
Sexual Dysfunction
|
Infection
|
|
Incontinence
|
Constipation
|
|
Weight Changes
|
Cancer
|
|
Neurological Concerns
|
Phychological Concerns
|
|
Musculoskeletal Concerns
|
Cardiac Concerns
|
|
Autoimmune Concerns
|
Physical Trauma
|
|
Emotional Trauma
|
Drug Abuse
|
|
Surgeries:
|
|
|
Prescription Medications:
|
|
|
Please Elaborate As Appropriate:
|
|
