Medical History Form Please fill the following fields Please enable JavaScript in your browser to complete this form.Full Name: *Email *Phone *Has this problem affected your daily life or routine? Briefly describe in what ways:Have you had past similar episodes of this current problem? If yes, were you treated with (chose disciplines which apply): *Physical TherapyAcupunctureMassage TherapistChiropractorPilatesGeneral ExerciseExercise with trainerSelf-medicated (Advil)Ignored itOtherDid they help to alleviate the symptoms? *Have you undergone any special tests for this condition? (X-rays, MRI's, etc.) If yes, do you have the results? *1) Do the current problems interrupt your sleep?YesNo2) Do your symptoms change with coughing or sneezing?YesNo3) Have you had any recent changes in bowel or bladder function?YesNo4) Do you experience any dizziness or vertigo?YesNo5) Have you had any recent changes in your weight or appetite?YesNo6) Do you have any intolerance to hot or cold?YesNo7) Do you have any bruising or bleeding disorders?YesNo8) Have you had any skin changes, such as rashes or discoloration?YesNo9) Have you experienced any changes in your vision, such as blurring, double vision, or decrease in your visual fields?YesNo10) Have you had a recent episode of nauseas/vomiting?YesNo11) Are you pregnant?YesNo12) Do you have osteoporosis? Date of your last bone scan:YesNoDate13) Do you have any allergies?YesNo14) Have you noticed any shortness of breath or decrease in exercise tolerance?YesNo15) Do you use any assistive device? (cane foot orthotics)YesNo16) Do you have high blood pressure?YesNo17) Do you have any cardiac problems?YesNo18) Do you have diabetes?YesNo19) Have you ever had cancer of any sort?YesNo20) Do you have a history of neck or back problems?YesNoAny other illness, past injuries I should be aware of?Past surgeries?YesNoGive brief details:List any medications you are currently taking (over the counter/prescription):Submit
