Joint/pain Evaluation Chart & Questionnaire Template Page 2
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2List current over the counter medications and nutritional supplements
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FAMILY MEDICAL HISTORY
F=Father
M=Mother
H=Husband
W=Wife
K=Kids
S=Sibling
G=Grandparent
Place the appropriate letter(s) in the blank if someone in your family has/had any of the following:
_____ Allergies
_____ Foot/Ankle Pain
_____ Anxiety
_____ Headaches (Migraines, Tension, etc)
_____ Arthritis/Joint Disease
_____ High Blood Pressure
_____ Asthma/Breathing Problems
_____ High Cholesterol
_____ Bed Wetting
_____ Knee Pain
_____ Bursitis (Shoulder, Hip, Etc…)
_____ Lower Back Pain
_____ Cancer – type? __________________________
_____ Neck Pain
_____ Carpal Tunnel Syndrome
_____ Numbness/Tingling – Where? ________________
_____ Depression
_____ Osteoporosis
_____ Diabetes – type? __________________________
_____ Plantar Fasciitis
_____ Digestive Disorder
_____ Sciatic Pain/Sciatica
(GERD/Reflux, Ulcers, IBS, Crohn’s, etc)
_____ Ear Infections (repeated/chronic)
_____ Shoulder Pain
_____ Fatigue/Low Energy
_____ TMJ/Jaw Pain
_____ Fibromyalgia
_____ Upper Back Pain
Please check any of the following services you would like more information about:
Chiropractic
Massage Therapy
Active Therapeutic Motion
Nutrition Response Testing
Cold Laser Therapy
Exercise Therapy
Whole Food Supplements
Health Coaching
Essential Oils
Weight Loss Program
Purification Detoxification
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Parent category: Medical