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Where did you find out about our office?
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Can we thank anyone for referring you?
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Do you want access to the online portal?
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Health History
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Is there a chance that you are pregnant? Yes / No
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Have you recently seen any of the following specialists?
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Have you had x-rays taken? Yes/No
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If yes, where?
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Been hospitalized in the past year? Yes / No
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If yes, what for?
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History of fractures/broken bones? Yes / No
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If yes, where?
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History of concussion or being struck unconscious? Yes / No
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Approximate Dates:
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History of surgery? Yes / No
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If yes, where?
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Coffee
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Alcohol
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Tobacco
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Drugs
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Exercise
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Sleep
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Appetite
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Special Diet
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Water
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Sugary Foods
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Artificial Sweeteners
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Soft Drinks
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Alcoholism Yes / No
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Allergies Yes / No
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Anemia Yes / No
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ArteriosclerosisYes / No
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Arthritis Yes / No
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Asthma Yes / No
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Back Pain Yes / No
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Blood thinning medications Yes / No
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Bronchitis Yes / No
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Bruise Easily Yes / No
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Cancer Yes / No
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Chest Pain/Conditions Yes / No
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Cold Extremities Yes / No
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Constipation Yes / No
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Muscle Cramps Yes / No
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Depression Yes / No
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Diabetes Yes / No
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Digestion Problems Yes / No
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Disc Pain/Injuries Yes / No
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Dizziness Yes / No
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Hearing Loss Yes / No
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Ears Ring Yes / No
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Excessive/Painful Menstruation Yes / No
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Eye Pain or Difficulties Yes / No
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Fatigue Yes / No
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Frequent Urination Yes / No
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Headache Yes / No
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Hemorrhoids Yes / No
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High Blood Pressure Yes / No
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Hot Flashes Yes / No
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Irregular Heart Beat Yes / No
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Irregular Cycle Yes / No
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Kidney Infections Yes / No
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Kidney Stones Yes / No
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Loss of Memory Yes / No
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Loss of Balance Yes / No
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Loss of Smell Yes / No
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Loss of Taste Yes / No
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Neck Pain or Stiffiness Yes / No
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Nervousness Yes / No
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Osteoporosis Yes / No
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Osteopenia Yes / No
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Pacemaker Yes / No
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Poor Posture Yes / No
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Prostate Trouble Yes / No
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Sciatica Yes / No
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Shortness of Breath Yes / No
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Sinus Infection Yes / No
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Sleep problems or Insomnia Yes / No
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Spinal Curvatures Yes / No
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Strokes Yes / No
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Swelling of ankles Yes / No
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Swollen Joints Yes / No
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Thyroid Condition Yes / No
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Tuberculosis Yes / No
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Ulcers Yes / No
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Varicose Veins Yes / No
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Venereal Disease Yes / No
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Any past illnesses we should be aware of?
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Other important information?
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Father's Medical History
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Mother's Medical History
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Grandparent's Medical History
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Sibling(s)' Medical History
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Please List Medications
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Please List Supplements
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