Medical History Intake Form Page 5
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8List Past Surgeries
None
List Past Hospitalizations
None
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List previous back, neck and musculoskeletal problems
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Mark if you have had any of the following symptoms in the past 5 years.
Females – Mark if have the following:
Unexplained fevers
Swollen ankles
Vaginal bleeding other than period
Night sweats
Stomach pain
Pap smear within last two years
Weight loss of 10 lbs or more
Change in bowel habits
Painful menstrual periods
Loss of appetite
Persistent diarrhea
Back pain with menstrual periods
Excessive fatigue
Excessive constipation
Other menstrual problems
Problems with depression
Dark black stools
Difficulty sleeping
Blood in stools
Do you have any current problem with:
Unusual stress at work
Pain-burning when urinating
anxiety
Unusual stress at home
Difficulty urinating – start / stop
depression
Easy bruising
Blood in urine
irritability
Excessive bleeding
Need to urinate more at night
Lumps in neck, armpit or groin
Morning stiffness
Chest pain or tightness
Persistent eye redness
Persistent or unusual cough
Muscle tenderness
Trouble breathing with exercise
Dry eyes or mouth
Trouble breathing lying flat
Skin rashes
Coughing up blood
Joint pain or swelling
Do you have a home exercise program that you follow on a regular basis?
Yes
No
Release Chiropractic and Wellness Center, 640 East Eisenhower Blvd. Suite 100, Loveland, CO 80537
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