Patient History Form

Patient History Form (page 2)
Patient Name (required)*

First NameLast Name
Please check those things ( that you have noticed) that help to reduce your symptoms:

injectionsmedicationstretchingrestheat or cold packsphysical therapychiropractic medicinemassagenothing
What kind of mattress do you sleep on?

firmmedium or pillow topsoft
How many pillows do you sleep with?

123 or more
In what position do you mainly sleep?

on my stomachon my backon my sideall of the above
Check the box next to each treatment you have previously had for your condition:

medicationinjectionschiropractic medicinephysical therapyspine surgery
Indicate any other treatment not listed above that you have had:
How many weeks of treatment have you already had?

none2 weeks or less2-4 weeks4-8 weeks8-12 weeks12 weeks or more
Check the boxes next to activities that make your symptoms worse:

coughingsneezingstraining when going to the bathroombreathing deepnone of the above
Do you have:

dizzinessringing in the earsnauseaswallowing difficultybladder problemsbowel problemsdifficulty walkingnone of the above
Indicate medications you are taking for pain and/or inflammation (including non-prescription medicines):
Do you consider your health, in general, to be:

goodfairpoor
Check any testing that you have had:

MRIX-RayCT-ScanBone ScanBlood tests
What date was the most recent testing done on?

MonthDayYear
* If you have had any of the tests listed above, try to bring the test results (CD and radiology report) with you to your appointment.
Should be Empty:

Patient History Form (page 2)