Patient Name
*
Occupation
*
Primary reason for this appointment
*
(i.e. chief complaints)
Please list other therapies currently engaged
Birth difficulties/trauma
Head trauma/concussion
Dental work
(tooth extractions, braces, etc.)
Car accidents, falls, sports injuries
Procedures & Dates
Please list all medications
Include prescriptions, non-prescription meds, herbal remedies, vitamins, supplements, etc. Include dosage and frequency.
Please list all allergies & sensitivites
Include drugs, foods, chemicals, environmental
Neurological
Please include dates & treatment.
Ears/hearing
Please include dates & treatment.
Respiratory
(sinus, mouth, throat, lungs) Please include dates & treatment.
Heart, blood pressure
Please include dates & treatment.
Digestive
(stomach, liver, intestines, hernia) Please include dates & treatment.
Urinary
(kidney, bladder) Please include dates & treatment.
Musculoskeletal
(muscles, ligaments, bones, spine) Please include dates & treatment.
Skin
(rashes, dryness, lesions, moles) Please include dates & treatment.
Endometriosis, fibroids, yeast infections, STDs
Pregnancies
Menstrual history
Prostate, STDs
PSA
PSA date and results
Traumas, illnesses, griefs, relocations, job loss, financial hardship, etc.
*
Please check all that apply
Immunizations
Tobacco
(how much, how often, # years)
Alcohol
(how much, how often, # years)
Recreational drugs
(name, how much, how often, # years)
Coffee/tea
(how much, how often, # years)
Hobbies
Exercise
Diet
(eating habits, food allergies, cravings, preferences)
Patient's father + paternal grandparents
*
(age or age when passed, diseases, conditions, traumas, allergies, significant life events)
Patient's mother + maternal grandparents
*
(age or age when passed, diseases, conditions, traumas, allergies, significant life events)
Patient's siblings
(age or age when passed, diseases, conditions, traumas, allergies, significant life events)
Patient's children
(age or age when passed, diseases, conditions, allergies)
