Health History Form

Full Name *

How did you hear about us?

Date of Birth

Home Address (Street, City, State, & Zip Code)

Primary Contact Number (Home, Work, or Mobile)

Date *

When did your symptoms start? *

Describe your symptoms, where they are on the body, and how they began: *

How often do you experience your symptoms? *

Constantly (76-100%)

Frequently (51-75%)

Occasionally (26-50%)

Intermittantly (0-25%)

What describes the nature of your symptoms? *

How are your symptoms changing? *

Getting Better

Not Changing

Getting Worse

How bad are your symptoms at their worst? *

How bad are your symptoms at their best? *

How do your symptoms affect your ability to perform daily activities? *

What activities make your symptoms worse: *

What activities make your symptoms better: *

Who have you seen for your symptoms? *

If you've been seen, when and what was done?

What tests have you had for your symptoms and when were they performed? (XRay, MRI, CT, etc)

Have you had similar symptoms in the past? *

Yes

No

If you have received treatment in the past for the same or similar symptoms, who did you see?

What is your occupation? *

What is your current work status?

What do you hope to get from your visit/treatment (select all that apply) *

Reduce Symptoms

Resume/Increase Activity

Explanation of condition/treatment

Learn how to take care of this on my own

How to prevent this from occurring again

What type of regular exercise do you perform *

What is your height? *

What is your weight? *

For each of the conditions listed below, check any that you are experiencing PRESENTLY: *

For each of the conditions listed below, check any that you have had in the PAST: *

Indicate if an immediate family member has had any of the folowing:

List all prescriptions and over the counter medications, and nutritional/herbal supplements you are taking: *

List all surgical procedures you have had and times you have been hospitalized: *

Insurance Carrier/Health Plan Name

Claims Address (Back of Insurance Card)

Subscriber ID

Please fill-out the form to the best of your ability and then “submit.” We will review all the information at your visit.

* If a question is required but you don’t have an answer, you can respond with “N/A.”*

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Please fill-out the form to the best of your ability and then “submit.” We will review all the information at your visit.

*** If a question is required but you don’t have an answer, you can respond with “N/A.”***

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* If a question is required but you don’t have an answer, you can respond with “N/A.”*