Patient Information Form (Page 3 of 4) in pdf

Bakke Chiropractic Clinic

HEALTH HISTORY FORM

Case#__________

List ALL medications you are presently taking. Include birth control and over-the-counter medications:

Medication: _______________________________ For what? ___________________________________

Drug Allergies: __________________________________________________________________________

After reading and filling out this case history, your signature verifies that all information provided is accurate

and that you have read the case history questions entirely.

Patient / Guardian Signature: _____________________________________ Date: ________________

THE FOLLOWING SECTION IS FOR WOMEN ONLY

Check the following conditions you have/have had:

o Painful menstruation

o Irregular cycle

o Lump(s) in breast(s)

o Menopausal symptoms

o Previous abnormal PAP

o Using Birth Control

Date of last period: ____________________________

Pregnant

Previous miscarriages



Please describe any other health problems or symptoms not already covered in this case history form:

__________________________________________________________________________________________

PREGNANCY WARNING AND CONSENT TO X-RAY

I understand that if I am pregnant and have x-rays taken which expose my lower torso to radiation, it is

possible to injure the fetus. I have been advised that if there is a chance I may be pregnant the 10 days

following onset of menstrual period are generally considered to be the safest time for an x-ray examination.

With full understanding of the above, and believing that I am not currently at risk, I give the doctors of

Bakke Chiropractic Clinic permission to perform an x-ray examination on me if they feel it is necessary.

Patient Signature: _____________________________________________ Date: _____________________

Form # HH Revised 04/01/15

Patient Information Form Page 3