Date of birth
EMERGENCY CONTACT: In case of an emergency, please contact: Name:
How long have you had this health concern?
What makes your health concern worse? (exercising, certain movements, heat, cold etc.)
What makes your condition better? (rest, heat, ice, etc.)
What other forms of treatment have you sought for this condition, when did you have these treatments, and were they helpful?
Please describe the condition in detail:
Please indicate if you have any significant illnesses:CancerDiabetesHepatitisHerpesHerniaHeart DiseaseHypertensionSeizures/EpilepsyStrokeArteriosclerosisVaricose veinsSleep apneaAsthmaHIVBlood clotting disorderEmotional DisordersInfectious DiseasesTuberculosisOsteoporosisSexually Transmitted Diseases
Any Drug allergies?YesNo
If Yes, please explain:
Do you follow any diet?
List any medications and supplements you are currently taking: (Continue on back if necessary.)
The information on this form is correct and accurate to the best of my knowledge