Health History
Patient Name
*
Responsible Party
*
Are you under the care of a physician?
*
Yes
No
Serious illnesses, injuries, or surgeries?
*
Yes
No
Are you on a special diet?
*
Yes
No
Medications
*
Do you have or have you had any of the following?
Asthma
*
Yes
No
ADD/ADHD
*
Yes
No
Bed Wetting
*
Yes
No
Breathing Problems
*
Yes
No
Cancer
*
Yes
No
Congestion
*
Yes
No
COPD
*
Yes
No
Diabetes
*
Yes
No
Dry Mouth
*
Yes
No
Easily Winded
*
Yes
No
Fainting Spells/Dizziness
*
Yes
No
Frequent Headaches
*
Yes
No
Frequent Urination
*
Yes
No
High Blood Pressure
*
Yes
No
Low Blood Pressure
*
Yes
No
Migraines
*
Yes
No
Neck or Shoulder Tension
*
Yes
No
Nightmares or Night Terrors
Yes
No
Pain in Jaw Joint
Yes
No
Sleep Apnea
*
Yes
No
Snoring
*
Yes
No
Stomach/Intestinal Disease
*
Yes
No
Tonsilitis/Adenectomy
*
Yes
No
Any other medical issues not listed
*
I consent that this information is accurate.
*
I consent to sharing information provided here.
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