MEDICATION / ALLERGY HISTORY
As of February 11, 2015, Waterbury Chiropractic Wellness started using an electronic health system and due to changes with Medicare and Obamacare we are required to have on file in your records the following information:
PATIENT NAME:
DATE OF BIRTH:
-
Month
-
Day
Year
Date
MEDICATIONS
Are you taking pain medications?
No
Yes, over the counter pain medications
Yes, prescribed pain medications
List your medications:
ALLERGIES
Allergy to Latex?
Yes
No
If yes, explain
Allergies to Medications:
Yes
No
If yes, explain
Food Allergies:
Yes
No
If yes, explain
Environmental Allergies:
Yes
No
If yes, explain
Other Allergies: explain
PAST SURGICAL HISTORY
Have you had prior spine surgery?
Yes
No
List Your Previous Surgeries
DIAGNOSTIC STUDIES
Indicate if you have undergone any of the following therapies or diagnostic studies for your condition:
Acupuncture
Anti-Depressant
Bed Rest
Behavior Therapy
Bone Density Study
Bracing / Immobilization
Chiropractor
CT of Brain
CT of Cervical Spine
CT of Lumbar Spine
CT of Pelvis
CT of Thoracic Spine
EMG Biofeedback
Exercise Therapy
Medications
MRI of Brain
MRI of Cervical Spine
MRI of Lumbar Spine
MRI of Thoracic Spine
Physical Therapy
Tens
Traction
X-Ray of Cervical Spine
X-Ray of Hip
X-Ray of Lumbar Spine
X-Ray of Thoracic Spine
Submit
Should be Empty: