First Name *

Last Name *

Date of birth *

Address *

City *

State *

Postal code *

Phone *

Spouse's Name

Spouse's Phone Number

Email *

Employed? *

Yes
No
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How did you hear about us? *

Height *

Weight *

General Symptoms (check all that apply) *

A-Fib

Arthritis in Feet

Arthritis in Hand

Asthma

Cancer

COPD

Degenerative Disc

Diabetes

Disc Issues

Excessive Thirst or Urination

Foot Numbness

Foot Pain

Foot Surgery

Hand Numbness

Hand Pain

High Blood Pressure

High Cholesterol

Hip Pain

Joint Replacement

Knee Pain

Leg Pain

Low Back Pain

Mobility Problems

Morton's Neuroma

Neck Pain

Nerve Poor

Organ Transplant

Pacemaker/Defibrillator

Plantar Fasciitis

Poor Circulation

Poor Wound Healing

Sciatica

Sleep Problems

Spinal Stenosis

Vascular Problems

Looking for General Wellness

None of the above

If you have cancer, please list location, metastasis, and type of treatment used.

Please list the issues you are interested in correcting in the order of importance *

Approximately how long have you noticed these symptoms? *

Do you smoke? *

Yes

If you smoke, how many cigarettes daily?

Do you drink? *

Yes

If you drink, how many drinks daily?

Do you exercise daily? *

Yes

If you exercise, how much exercise daily?

Name of Primary Care Provider

Phone Number of Primary Care Provider

List any previous surgeries with the date they occurred

List all allergies or sensitivities to food, medication, etc.

How do you react to those allergies?

List any prescription drugs you are taking along with dosage and frequency.

List all nutritional supplements (vitamins, herbs, homeopathies, etc.) along with dosage and frequency.

This is a confidential record of your medical history. The practitioner reserves the right to discuss this information with medical professionals within our group. Copies of this record can only be released with your specific authorization.

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