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MEDICAL HISTORY AND PREVIOUS TREATMENT FORM

PATIENT NAME:
                                                                                                   Date:                                    
Please check if you have been diagnosed with any of the following conditions:

Diabetes	Heart Disease	High Blood Pressure
Cancer	Pacemaker	Stroke (TIA or CVA)
Seizures	Metal Implants	Fractures
Back Pain	Hemophilia	Previous Surgeries
Pregnancy	Respiratory Problems	Other

Please list all medications you are currently taking:                                                                       
                                                                                                                                                     

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Have you had the same or a similar problem in the past?   Yes                No             

If yes, Please explain:                                                                                                                     

Please explain any specific treatment you have received for this problem, such as previous physical or occupational therapy, chiropractic visits, pain medication, etc.

Has your doctor discussed your medical findings or given you a diagnosis? Yes           No         

If yes, what were the findings?

Do you have allergies?   Yes          No        If yes, please list:                                                        

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What are your goals for recovery?

        Increase in movement          Return to work          Return to sports
         Increase in strength          Other:                                                                          

Are you aware of any physical reason why you should not receive treatment? Yes         No         

If yes, please tell us what it is:                                                                                                         

Thank you for completing this questionnaire. It will allow us to better serve your needs.

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