Health History Form
Date
Full Name
Street Address
City
State
Zip
Email
Age
Birthdate
Marital Status
Children
Work Phone
Home Phone
Cell
How did you find us?
Patient Referral
Google Search
Other Search (Yahoo, Bing, etc.)
Facebook
Other
How did you find us? Patient referral? Online? Other?
What is the main problem you would like to address?:
How long has it been since you first noticed any symptoms?:
Have you been referred to or given a diagnosis by an MD or chiropractor?:
Falls/Accidents - related to incident and as far back as you can remember. Have you experienced any major accidents or significant trauma (physical or emotional)?:
Present Therapies - Are you seeing another practitoner?:
Past Therapies:
To what extent does your problem affect your daily activities - work, sleep, play, eating, etc.?:
Past Medical History - anything you think might be pertinent:
Past Surgical History - when, for what reason?:
Dental History - orthodontics, TMJ, extractions, other:
List prescription medications (and recreational drugs):
List over the counter medications and vitamins, herbs, supplements:
Food Allergies?:
Work Stress factors
How long is your commute?:
How many hours a week do you work?:
How many hours a day do you work at a computer?:
Are there other physical, psychological, chemical stressors at work?:
Do you enjoy your work? If not why?:
Lifestyle
Do you follow a regular exercise program? Describe:
Do you wear orthotics?:
Do you eat 3 meals a day?:
If not, how many?:
Describe your diet:
Coffee, tea, caffeinated soft drinks - cups per day:
Tobacco - packs per day?:
Sleep Patterns
How many hours do you sleep each night?:
If you get up, do you fall back asleep without a problem?:
Do you wake up rested?:
Do you wake up with stiffness? If so, where?:
Support network - what resources do you have in your life? (person, place, animal):
Emotional factors - anxiety, mood swings, depression:
Energy - Fatigue, chronic infections, chronic fatigue:
Family History
Birth order:
Siblings:
Any major illnesses in family history - Cancer, diabetes, high blood pressure, stroke, mental illness, allergies:
Childhood Illnesses - hospitalizations, ear infections, respiratory problems, phobias, any knowledge of birth history:
Allergies:
Other general symptoms - headaches, chills, dizziness, nervousness, numbness/pain in arms, hands, legs, depression, tinnitus, digestive, urinary, hormonal:
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