Personal Health History Template
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1Personal Health History
Date _________________
Name _______________________________________
Referred By __________________________________
How would you like to be addressed?______________
Social Security # _______________________________
Address _____________________________________
Occupation ___________________________________
City ____________________ State ____ Zip ________
Employer ____________________________________
Phone: (H) _______________ (Cell) ________________
Marital Status
S
M
D
W
E-mail _______________________________________
Date of Birth _______________ (Age ______)
Current Health Condition
Present Complaint (be brief) Reason For Your Visit Today:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Pain or Problem started on__________________________________________________________________________
Sharp
Dull
Constant
Intermittent
Pains are:
What activities make your condition worse? __________________________________________________________
What activities improve your condition? ______________________________________________________________
Is condition worse during certain times of the day? _____________________________________________________
Is this condition interfering with work? ______ Sleep? ______ Routine? ______ Other? _______
Is this condition getting progressively worse? _________________________________________________________
Other Doctors seen for this condition ________________________________________________________________
Any home remedies? ____________________________________________________________________________
Other symptoms:
Headaches
Face Flushed
Light Bothers Eyes
Feet Cold
Neck Pain
Neck Stiff
Loss of Memory
Hands Cold
Sleeping Problems
Pins & Needles in Legs
Ears Ring
Stomach Upset
Back Pain
Pins & Needles in Arms
Fever
Constipation
Nervousness
Numbness in Fingers
Fainting
Loss of Balance
Tension
Numbness in Toes
Cold Sweats
Buzzing in Ear
Irritability
Shortness of Breath
Loss of Smell
Chest Pains
Fatigue
Loss of Taste
Dizziness
Depression
Diarrhea
Have you been under drug and medical care? ________________________________________________________
What medications are you taking? _________________________________________________________________
How Long? _________________ Have you had surgery? ________________ What? ________ When?__________
What side effects have you experienced from the drugs and surgery? ______________________________________
Is there a family history of:
Heart Disease
Arthritis
Cancer
Diabetes
Other _______________
Father’s Side
Mother’s Side
Upon the completion of your first visit, you will receive a Chiropractic Report to discuss the different types of Active Life
Plans that are available to you. Chiropractic Active Life Plans are designed to help get you feeling better quickly and to
help you and your family be as healthy as possible. Please review the explanations of the Chiropractic Active Life Plans
prior to your Chiropractic Report appointment so you can choose the level of participation that supports you in reaching
all of your health goals.
As a result of my chiropractic care, I would like to
Please check all that apply
Feel better quickly
Have a healthier body by keeping my nerve system healthy
Have a healthier spine
Live a healthier lifestyle
__________________________________________
___________________
Signature
Date
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Parent category: Medical