Free Chiropractic Clinic Health History Form Template
Chiropractic Clinic Health History Form
Please complete this form to help us better understand your health history.
Patient Name
Date of Birth
Gender
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Male
-
Female
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Home Address
Phone Number
Email Address
Have you experienced any of the following conditions?
Check all that apply:
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Back Pain
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Neck Pain
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Headaches or Migraines
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Osteoporosis
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Arthritis
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List any surgeries or hospitalizations:
Please include the dates.
List any allergies you may have:
List any medications or supplements you're currently taking:
Consent and Acknowledgment
By signing below, I confirm that the information provided is accurate and complete to the best of my knowledge.
Name:
Date:
Thank you for your submission!
We appreciate you taking the time to submit.
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