Chiropractic Intake Form Page 3
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4Please list all
medications you take
and what they are
used for:
Please briefly tell us
about your family's
health history
including siblings,
parents and
grandparents health
condition's:
System Review:
Please check any conditions that you have or have had in the past 6 months:
General Symptoms
Fever
Respiratory
Chronic cough
Sweats
Spitting up blood
Fainting
Wheezing
Sleep disturbance
Chest pain
Fatigue
Asthma
Unexplained weight gain
Unexplained weight loss
Genitourinary
Frequent urination
Neurological
Fainting
Painful urination
Dizziness
Blood in urine
Numbness
Kidney infection
Poor coordination
Prostrate trouble
Seizures
Headache
Weakness
Cardiovascular
Rapid heart beating
Gastrointestinal
Excessive thirst
Slow heart beating
Indigestion
Blood pressure
Heartburn
Hardening of arteries
Nausea
Swollen ankles
Vomiting
Poor circulation
Constipation
Palpitations
Diarrhea
Cold hands or feet
Blood in stool
Varicose veins
Gallbladder issues
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Parent category: Business