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How did you hear about our office?
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If referred, by whom?
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Do you want access to the online portal?
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Health History
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Please List Prescription Medications
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Please List Current Over The Counter Medications
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Have you had imaging taken? Yes/No
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If yes, what body part and what imaging modality?
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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 Motor Vehicle Accidents? Yes / No
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If yes, when?
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History of surgery? Yes / No
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If yes, where?
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Other Spine Specific Surgery?
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If yes, where?
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Habits
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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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Please List Supplements
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Water
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General Symptoms
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Allergies
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Asthma
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Dizziness/Vertigo
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Fainting
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Fatigue
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Headache
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Nausea
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Numbness/Pain into Hands/Feet
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Musculoskeletal
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Hernia
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Arthritis
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Osteopenia/Osteoporosis
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Swollen Joints
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Spinal Curvatures/Scoliosis
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Disc Pain/Injuries
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Sciatica
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Other:
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Cardiovascular
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Anemia
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Arteriosclerosis
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Blood thinning medications
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High Blood Pressure
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Bruise Easily
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Cold Extremities
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Irregular Heart Beat
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Pacemaker
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Swelling of ankles
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Other:
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Respiratory
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Shortness of Breath
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Bronchitis
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Chest Pain/Conditions
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Other:
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Neuro/Psych
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History of Stroke
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Loss of Balance
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Loss of Memory
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Depression
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Anxiety
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Sleep problems or Insomnia
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History of Seizures
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Other:
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Metabolic
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Diabetes
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Cancer
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Thyroid Condition
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Other Endocrine Disorder
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Blood Disorder
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Other:
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Gastrointestinal
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Digestion Problems
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Constipation
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Abdominal Pain
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Hemorrhoids
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Incontinence
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Other:
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Genitourinary
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Kidney Stones
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Kidney Infections
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Ulcers
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Prostate Trouble
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Frequent Urination
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Other:
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Eye/Ear/Nose/Throat
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Eye Pain or Difficulties
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Ears Ring
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Hearing Loss
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Nose Bleeds
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Loss of Smell
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Sinus Infection
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Loss of Taste
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Other:
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Women Only
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Excessive/Painful Menstruation
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Hot Flashes
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Irregular Cycle
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Is there a chance that you are pregnant?
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History of Miscarriage
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Other:
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Fill In
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Any past illnesses we should be aware of?
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Other important information?
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Family History
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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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Anxiety
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