southcenterchiropractic.com - Health History Form

Musculoskeletal

HeadachesTMJ painNeck ache/painUpper back ache/painMid back ache/painLower back ache/painHip Pain L RShoulder pain L RElbow/Forearm pain L RHand/Wrist pain L RKnee ache/pain L RFoot/Ankle pain L RHerniaMuscle pain/weaknessOther

Neurological

Head/Eyes/Ears/Nose/Throat

Cardiovascular

Respiratory

Genito-Urinary

Gastro-Intestinal

General

List of Medications & Supplements

When was your last period?

Are you pregnant?

yesnounsure

If yes, due date

Date

Type of period

Diseases

Check the appropriate boxes in the Father, Mother, Sibling, and Grandparent, if someone in your family has/had any of the following:

	Yes/ No	Father	Mother	Sibling	Grandparent
Mental Illness
Diabetes
Hepatitis
Arthritis
AIDS
Herpes
Stroke
HIV+
Chronic Fatigue
Gall Stones
Osteoporosis
Mononucleosis
Rheumatic Fever
Thyroid Problems
Parasites
Cancer
Heart Disease
Asthma
Allergies
Seizures
Ulcers
Kidney Stones
Venereal Disease
High Blood Pressure

Other

Patient/Guardian Signature

Date

Present Health History

List Complaints

Have you received any of the following care before?

Habits

Lifestyle

General Health History

Check all that apply and note left or right if applicable

Gynecological (For Women)

Family Health History