largechiropracticclinic.com - Patient Health History Form

PATIENT NAME

First NameLast Name
PAST HEALTH HISTORY FORM
The following may seem unrelated to the purpose of your appointment; however, these questions must be answered carefully as these problems can affect your overall course of chiropractic care.
PLEASE CHECK ALL THAT APPLY
MAJOR SURGERIES/OPERATIONS:

Other
MAJOR ACCIDENT OR FALLS (OTHER THAN WHAT YOU ARE BEING SEEN FOR TODAY)
HOSPITALIZATION (OTHER THAN ABOVE)
PLEASE LIST ALL PRESCRIPTION AND OVER-THE-COUNTER MEDICATIONS YOU ARE CURRENTLY TAKING
DO YOU WEAR A SHOE LIFT?
CHECK ANY OF THE FOLLOWING DISEASE YOU HAVE HAD:
Intake
Coffee, Cups/Day
Tea, Cups/Day
Alcohol, Drinks/Week
Cigarettes, Packs/Day
CHECK ANY OF THE FOLLOWING YOU HAVE HAD REGULARLY THE PAST 6 MONTHS
MUSCULO-SKELETAL
EENT
GASTRO-INTESTINAL
C-V-R
MALE/FEMALE

Other Problems
NERVOUS SYSTEM
GENITO-URINARY
GENERAL
FEMALES ONLY:
When Was Your Last Period?
Are You Pregnant?
FAMILY HISTORY
The following members have a same or similar problem as I do
Patient/Parent-Guardian Signature
Today’s Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

PAST HEALTH HISTORY FORM