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Have you had or do you now have any of the following symptoms/conditions? Please indicate the conditions you have
now with a CHECK MARK if you have had these conditions previously.
Allergies/Asthma
Sleeping Problems
Broken Bones/Fractures
Tension
Depression
Weight Gain/Loss
Seizures/Epilepsy
Skin Conditions
Eating Disorders
Ulcers
Fainting
Loss of Balance
Nervousness
Stroke
Arthritis
Diabetes
Chest Pain/Tightness
Muscle Spasms
Breathing Problems
Dizziness
Numbness in Fingers
Fatigue
Sinus Problems
Pacemaker
Weakness in Extremities
Joint Pain/Swelling
Loss of Memory
Circulation Problems
Osteoarthritis
Heart Disease
Cancer
Rheumatoid Arthritis
HIV Positive
Other __________________________
SOCIAL HISTORY
Please indicate beside each activity whether you engage in it:
OFTEN= O SOMETIMES= S NEVER= N
__________ Exercise
_________ Family Pressures
__________ High Stress Activity
_________ Financial Pressures
__________ Alcohol Use
_________ Other Mental Stresses
__________ Drug Use
Other (specify)________________
__________ Tobacco Use
____________________________
__________ Caffeine
____________________________
Use the area below to tell us where you'd like to focus, to avoid, and to describe your symptoms and pain:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Mark your pain and problem areas and beside them rate it on a scale of 0-10. 0 means no pain, 10 is you need to be
taken to the emergency room immediately.
I CERTIFY THAT THE INFORMATION PROVIDED IS ACCURATE TO THE BEST OF MY KNOWLEDGE AND WILL
NOTIFY THIS PRACTICE OF ANY CHANGES IN MY HEALTH AND/OR MEDICATIONS AS NEEDED. I UNDERSTAND
THAT THIS INFORMATION IS TO HELP TREAT ME TO THE BEST OF THE PRACTITIONERS ABILITY.
Signature of Patient or Legal Guardian: ______________________________________________________________
Date: _____________________________ Therapist's Initials ____________________________________________