Confidential Health History Form

What are your treatment goals?

Do you exercise regularly and/or participate in any sports? If yes, please list your types of exercise and/or sports.

Do you have any recent injuries, areas of inflammation, or recent surgeries (within the past year)? Please list and briefly explain.

Are you taking any medications? Instead of listing the names of the medications, please briefly list what your medications are for. (ex. colesterol, allergies, mood, pain, blood pressure, blood thinner, hormone replacement, seizures, migraines, etc)

Do you have any type of contagious disease or skin condition? (ex. HIV, AIDS, Hepatitis, MRSA, poison ivy)

Are you pregnant? When is your due date?

Are there any other conditions that would be helpful for me to know about?

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Health History Intake Form