Chiropractic Appointment Reminder Letter Template Page 9
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Name________________________Date__________________
Women Only
Men Only
Past Current
Problems with Breasts
Past
Current
Prostate Problems
Vaginal Itch/Discharge
Impotence
Painful Intercourse
Swollen or Painful Testicle
Take Birth Control Pills
Discharge
Irregular Cycles/Bleeding
Hot Flashes
Difficulty Conceiving
Age of First Period
# of Pregnancies
# of Miscarriages
# of Abortions
Passed Menopause at Age
Date/Onset of last period:
# of Days between cycles:
Family History:
State Health Problems or
Relationship
Age, if Living
Age, at Death
Cause of Death
Father
_________
_________
___________________________________
Mother
_________
_________
___________________________________
Brothers
_________
_________
___________________________________
Sisters
_________
_________
___________________________________
Grandfather
_________
_________
___________________________________
Grandfather
_________
_________
___________________________________
Grandmother
_________
_________
___________________________________
Grandmother
_________
_________
___________________________________
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