General Patient Information
Name
*
First Name
Last Name
Gender
*
Male
Female
Birth Date
*
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Year
E-Mail
*
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Patient Medical History
Please list any drug allergies
Have you ever had (Please check all that apply)
Asthma
Arthritis
Cancer
Diabetes
Epilepsy Seizures
Fainting Spells
Gallstones
Heart Disease
Heart Attack
High Blood Pressure
Kidney Disease
Liver Disease
Lung Disease
Emphysema
Skin Disorders
Low Blood Pressure
Abdominal/Digestive problems
Varicose Veins
Other illnesses:
Please list any Operations and approximate Dates of Each
Please list your Current Medications
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Current Complaint/Symptoms
Which of the following describes what you are experiencing?
Type of symptom
Pain
Ache
Discomfort
Tension
Numbness
Tingling
Describe the Severity
Mild
Moderate
Disabling
Constant
Intermittent
Cramping
Dull
Sharp
Shooting
How constant are your symptoms?
Getting worse
Staying the same
Getting better
Increases with activity
Decreases with activity
No change
Wakes me at night
No change to sleep pattern
What is your priority for treatment?
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