PATIENT HISTORY INFORMATION
After filling the details click on the SUBMIT button.

* indicates required fields 
  *Full Name:
  *Street Address:
  *City:
  *State:
  *Zip:
  *Country:
  *Home Phone:
  *Work Phone:
  *Cell Phone:
  *Email Address:
  *Marital Status:
  *Date of Birth:
  *Age:
  Social Security #:
  *Number of children:
  Employer:
  *Occupation:
  *How did you find out about us (who referred you):
  *Explain problem in detail:
  *Name of All Doctors visited: D.C., M.D., LAC.,Etc.:
  If Yes, whom did you see:
  *Do you have any medical records:  YES
 NO
  *Can you provide medical records:  YES
 NO
  *What do you consider your health status:
  *Weight gain or loss in past year:  YES
 NO
  Weight gained if any:
  Weight lost if any:
  *Name of Family Doctor:
  *LIST SERIOUS ILLNESSES IF ANY:
  *LIST ALLERGIES IF ANY:
  *LIST PREVIOUS SURGERIES IF ANY:
  *LIST ALL MEDICATIONS IF ANY:
  *LIST ALL VITAMINS IF ANY:
  *DO YOU SMOKE:  YES
 NO
  *DOES ANY ONE IN HOUSEHOLD SMOKE:  YES
 NO
  *Any Family History of:  Angina
 Cancer
 Asthma
 Diabetes
 Seizures
 High Blood Pressure
 Mental Illness
 Kidney Disease
 Heart Disease
 NONE OF THE ABOVE
  *Neurological problems:  Weak Grip
 Hand Trembling
 Epilepsy
 Difficulty Speech
 Loss of Memory
 Loss of Sensation
 Paralysis
 Tingling
 Seizures
 NONE OF THE ABOVE
  *Mental/Emotional problems:  Anger
 Fears
 Insomnia
 Low Self Esteem
 Difficulty Socializing
 Control Issues
 Depression
 Concentration-Focus Problem
 Anxiety-Painc Attacks
 NONE OF THE ABOVE
  *Musculoskeletal problems:  Muscle Pain
 Muscle Cramps
 Muscle Twitching
 Muscle Weakness
 Joint Stiffness
 Joint Pain
 NONE OF THE ABOVE
  *General conditions:  TMJ
 Bruise easily
 Anemia
 Eye Surgery
 Latex allergies
 High blood pressure
 Skin problems
 Shortness of breath
 Pregnant
 NONE OF THE ABOVE
  *Other Complaints:  Night sweats
 Temperature intolerance
 Lightheadedness
 Weakness
 Fatigue
 Vertigo
 Fainting
 Dizziness
 Numbness
 NONE OF THE ABOVE
  Other Comments:

Please press SUBMIT tab when done. Thank you..
 
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