Past Medical Treatment

Recent Medical Specialist Treatment:

Past Spine Surgery History?

Yes

Specific Spine Surgeries:

Past Joint Surgery History?

Yes

Specific Joint Surgeries:

Past Spine Injections?

Yes

Specific Spine Injections:

Past Joint Injections?

Yes

Specific Joint Injections:

If applicable, provide details about any other treatments you have had for your primary area of concern:

Drug Allergy History?

Yes

Specific Drug Allergy:

Drug Allergy 1
Drug Allergy 2
Drug Allergy 3
Drug Allergy 4
Drug Allergy 5
Drug Allergy 6
Drug Allergy 7
Drug Allergy 8
Drug Allergy 9
Drug Allergy 10

Past Medical History

Please indicate below any conditions you have been diagnosed with by a healthcare provider.

Cardiovascular (Heart & Vascular) History?

Yes

Cardiovascular (Heart & Vascular) Diagnoses:

High Blood Pressure (Hypertension)

Coronary Artery Disease (CAD) or Heart Attack

Heart Failure (e.g., Congestive Heart Failure)

Heart Valve Problems (e.g., Mitral Valve Prolapse)

Arrhythmias (e.g., Atrial Fibrillation)

High Cholesterol or Lipid Disorders

Peripheral Vascular Disease (PVD)

Respiratory (Lung & Breathing) History?

Yes

Respiratory (Lung & Breathing) Diagnoses

Gastrointestinal (Stomach & Intestines) History?

Yes

Gastrointestinal (Stomach & Intestines) Diagnoses

Gastroesophageal Reflux Disease (GERD) or Chronic Heartburn

Irritable Bowel Syndrome (IBS)

Inflammatory Bowel Disease (Crohn’s, Ulcerative Colitis)

Peptic Ulcers

Chronic Hepatitis or Liver Disease

Gallbladder Disease (Gallstones, Cholecystitis)

Pancreatitis

Neurological (Brain & Nerves) History?

Yes

Neurological (Brain & Nerves) Diagnoses

Genitourinary (Kidney & Urinary Tract) History?

Yes

Genitourinary (Kidney & Urinary Tract) Diagnoses

Chronic Kidney Disease or Kidney Failure

Kidney Stones

Urinary Tract Infections (Frequent/Chronic)

Prostate Disorders (e.g., Benign Prostatic Hyperplasia)

Urinary Incontinence

Endocrine & Metabolic History?

Yes

Endocrine & Metabolic Diagnoses

Diabetes Mellitus (Type 1 or Type 2)

Thyroid Disorders (Hypothyroidism, Hyperthyroidism)

Adrenal Disorders (Addison’s, Cushing’s)

Polycystic Ovary Syndrome (PCOS)

Metabolic Syndrome

Hematologic (Blood & Lymph) History?

Yes

Hematologic (Blood & Lymph) Diagnoses

Anemia (Iron-Deficiency, Sickle Cell, etc.)

Clotting Disorders (Hemophilia, Factor V Leiden)

Leukemia, Lymphoma, or Other Blood Cancers

Low Platelets or Other Blood Cell Abnormalities

Musculoskeletal (Bones, Joints, Muscles) History?

Yes

Musculoskeletal (Bones, Joints, Muscles) Diagnoses

Autoimmune & Immunologic History?

Yes

Autoimmune & Immunologic Diagnoses

Behavioral & Psychological History?

Yes

Behavioral & Psychological Diagnoses

Oncologic (Cancer) History?

Yes

Oncologic (Cancer) Diagnoses

Dermatologic (Skin) History?

Yes

Dermatologic (Skin) Diagnoses

Infectious Disease History?

Yes

Infectious Disease Diagnoses