Please choose all current and past medical conditions No medical condition(s) Apnea Rheumatoid arthritis □ □Sleep □ High blood pressure Lupus Bleeding disorder(s) □ □ □ Heart attack Parkinson’s Disease Anemia □ □ □ Abnormal heart rhythm Diabetes Type Blood clots □ □ – □ Lung disease/COPD Thyroid Type: Hyper/Hypo Schizophrenia □ □ – □ Tuberculosis Stomach ulcers Anxiety □ □ □ Asthma IBS Depression □ □ □ Bronchitis Stroke HIV □ □ □ Emphysema Seizures Alcoholism □ □ □ Disease Cancer Type Anorexia/bulimia □ □ – □ Hepatitis Type Kidney failure Heart murmur □ – □ □ Irregular heartbeat Osteoporosis Cheat pain □ □ □ * Are you under the care of another physician for ANY OTHER medical condition? Yes No If yes, please □ □ provide name and number and reason for care Surgical History Please choose all surgeries you have had: None □ Spine Neck: Level(s) Date: Hernia/ Colon/ Rectum □ – □ □ □ Spine Back: Level(s) Date: Hysterectomy/ C-section □ – □ □ Brain Carpel Tunnel Left/Right Shoulder(s) Left/Right □ □ – □ – Heart Hip(s) Left/Right Knee(s) Left/Right □ □ – □ – Angioplasty/ Stent Eye(s) Left/Right Throat/ Tonsils □ □ □ – □ □ Lung Other: □ □ Gallbladder/ Stomach □ □ Appendix/ Intestine □ □ Medication History Please list ALL medications including the dose. Please include over the counter medications and vitamin supplements. None □
Please choose all current and past medical conditions □ No medical condition(s) □Sleep Apnea □ Rheumatoid arthritis □ High blood pressure □ Lupus □ Bleeding disorder(s) □ Heart attack □ Parkinson’s Disease □ Anemia □ Abnormal heart rhythm □ Diabetes – Type □ Blood clots □ Lung disease/COPD □ Thyroid – Type: Hyper/Hypo □ Schizophrenia □ Tuberculosis □ Stomach ulcers □ Anxiety □ Asthma □ IBS □ Depression □ Bronchitis □ Stroke □ HIV □ Emphysema □ Seizures □ Alcoholism □ Disease □ Cancer – Type □ Anorexia/bulimia □ Hepatitis – Type □ Kidney failure □ Heart murmur □ Irregular heartbeat □ Osteoporosis □ Cheat pain * Are you under the care of another physician for ANY OTHER medical condition? □ Yes □ No If yes, please provide name and number and reason for care Surgical History Please choose all surgeries you have had: □ None □ Spine – Neck: Level(s) Date: □ Hernia/ □ Colon/ □ Rectum □ Spine – Back: Level(s) Date: □ Hysterectomy/ □ C-section □ Brain □ Carpel Tunnel – Left/Right □ Shoulder(s) – Left/Right □ Heart □ Hip(s) – Left/Right □ Knee(s) – Left/Right □ Angioplasty/ □ Stent □ Eye(s) – Left/Right □ Throat/ □ Tonsils □ Lung □ Other: □ Gallbladder/ □ Stomach □ Appendix/ □ Intestine Medication History Please list ALL medications including the dose. Please include over the counter medications and vitamin supplements. □ None
Patient-Paperwork.docx