Medical History Form
Crystal McLain, LMT
Name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
What brings you to the office? What would you like to address?
*
Overall, how would you describe your physical, emotional, and mental health?
*
What medications are you currently taking?
*
Please list any injuries or surgeries.
*
Please list any NEUROLOGICAL conditions you currently have, or have had in the past. (Example: Shingles, Seizures, Dizziness, Tingling, Parkinson's) :
Please list any CARDIOVASCULAR ( conditions you currently have, or have had in the past (Example: Heart Attack, Pacemaker, Lymphedema, Blood Clots, Vericose Veins):
Please list any IMMUNE conditions you currently have, or have had in the past. (Example: Allergies, Lupus, Cancer, Rheumatoid Arthritis) :
Please list any MUSCULOSKELETAL conditions you currently have, or have had in the past. (Example: Tendonitis, Gout, Artificial Joints, Osteoporosis, Scoliosis):
Please list any GASTROINTESTINAL conditions you currently have, or have had in the past. (Example: IBS, Crohn's Disease, Constipation, Eating Disorder):
Please list any BLOOD conditions you currently have, or have had in the past. (Example: HIV/AIDS, High Cholesterol, Embolism/Thrombosis, Hepatitis):
Please list any SKIN conditions you currently have, or have had in the past. (Example: Hypersensitive Reactions, Herpes, Melanoma, Psoriasis, Rosecea):
Please list any RESPIRATORY conditions you currently have, or have had in the past. (Example: Asthma, Chronic Cough, COPD, Emphysema, Cystic Fibrosis):
Please list any OTHER conditions you currently have, or have had in the past. (Example: Tinnitus, Kidney Stones, Diabetes, Insomnia):
Is there anything else you would like me to know?
Submit
Should be Empty: