Health history form


How did you find out about us?
Date of Birth
Gender*
Is your general health good?*
Has there been a change in your health within the last year?
Have you gone to the hospital or emergency room or had a serious illness the last three years?
Are you being treated by a physician now?
Are you in pain now?
Have you done any spinal cord surgery?
 
Please select which of the following have you experienced
 
Have you had or do you have any of the following
 
Are you allergic to or have you had reaction to any of the following
 
Are you taking or have taken any of the following in the last three months:
Women only:
Are you or could you be pregnant?
Are you nursing?
Are you taking birth controlling pills?
All patients
Do you have any other diseases or medical condition NOT listed on this form?*