Medical History Form

Medical History Form

This medical history form asks basic information about the patients medical history, sufferings, family information and habits. This has drawing board widget where patient can point which part of the body he/she is suffering pain. Form Preview
  • MEDICAL HISTORY

  • Using the pain drawing, please mark the areas on your body where you feel the pain:

    • Family History  
    • Habits  
    •  
    • Please mark if you ever had any of the following:

    • General Symptoms  
    •   Never Previously Presently
      Allergy
      Convulsions
      Dizziness
      Fainting
      Fatigue
      Headache
      Nervousness
      Neuralgia
      Numbness
      Pain in arms/legs/hands
    • Muscles & Joints  
    •   Never Previously Presently
      Backache
      Foot trouble
      Hernia
      Pain between shoulders
      Painful tail bone
      Stiff neck
      Spinal curvature
      Swollen joints
      Tremors
      Twitching
      Weakness
    • Cardiovascular  
    •   Never Previously Presently
      High blood pressure
      Low blood pressure
      Pain over heart
      Poor circulation
      Previous heart trouble
      Stroke
      Swelling of ankles
      Varicose veins
      Chest pain
      Chronic cough
      Difficulty breathing
    • Operations & Procedures  
    • Please list dates of all previous operations and/or procedures

    •  
    • I hereby auhtorize the Doctors of Grennan Chiropractic to examine and treat my condition as deemed appropriate through the use of Chiropractic Care, and give authority for these procedures to be performed. It is understood and agreed the amount paid to the Doctor for Xrays is for examination only and the Xray negatives will remain the property of this office, being on file where they may be seen at any time while a patient of the office. The patient also agrees that he/she is responsible for all bills incurred at this office. The Doctor will not be held responsible for any pre-existing medically diagnosed conditions nor for any medical diagnosis.

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