An accurate health history is important to ensure that it is safe for you to receive osteopathic treatment. All information gathered for this treatment is confidential except as required or allowed by law.
Name:
Last Name:
Email Address:
Address:
City:
Postal Code:
Date of Birth: January February March April May June July August September October November December
Occupation:
Reason for Consultaion:
Health History: Please check all that you are experiencing or have experienced.
(Specify its nature, i.e. Pain, stiffness, numbness, etc.)
Neck
Shoulder
Upper Back
Mid Back
Lower Back
Arms
Legs
Knees
Hip
Other
Tension
Migraines
Tooth / Jaw / Ear Pain
Head Trauma: January February March April May June July August September October November December
Symptoms:
Physical Limitaions:
Car Accident
Work Related
Date of Accident: January February March April May June July August September October November December
Chronic Cough
Asthma
Sinus Problems
Shortness of Breath
Emphysema
Bronchitis
Pneumonia
High Blood Pressure
Low Blood Pressure
Stroke / CVA
Angina
Heart Attack
Plebitis
Heart Disease
Pacemaker
Chronic Congestive Heart Failure
Hepatitis
Tuberculosis
HIV
Pregnant Due Date: January February March April May June July August September October November December
Skin Condition
Herpes
Lose of Sensation
Bruise Easily
Varicose Veins
Neurilogical Conditions:
Epilepsy
Diabetes / Onset
Cancer
Arthritis
OA
RA
Where:
Surgery:
Type:
Date of Surgery: January February March April May June July August September October November December
Current Symptoms
Pins / Wires / Prosthetics:
Yes
No
If yes, specify:
Elaborate on any of the above:
Message: (Required)
I have read the above information and have stated all my previous and current medical conditions. I understand that this information is used only to determine the suitability for osteopathic treatments.