Select any of the following medical conditions or diseases that you have or had:

Heart attack / stroke	Heart Surgery and/or Pacemaker	Heart Murmor
Congenital heart defect	Mitral Valve Prolapse	Artificial Valves
Alcoholic or Drug addict	Venereal Disease	Hepetitis
HIV / AIDS	Shingles	Cancer
Frequent neck pain	Emphysema / Glaucoma	Anemia
High/Low Blood Pressure	Psychiatric Problems	Rheumatic Fever
Severe or Frequent headaches	Kidney Problems	Ulcers / Colitis
Fainting/Seizures/Epilepsy	Sinus Problems	Asthma
Diabetes/Tuberculosis	Difficulty Breathing	Chemotherapy
Lower back problems	Artificial Bones / Joints	Arthritis

 

 

 

 

 

 

Please list any other medical condition(s) you have or had:

Please list anything you are allergic to:

Please list previous surgeries with dates:

Please list any past serious accidents with dates:


Do you smoke? Y N How much? N/A 1-5 day 6-10 day 11-19 day 1 pack a day 2 packs a day 3 packs a day more than 3 packs a day How long? N/A 1 month 6 months 1 year 2 years 3 years 4 years 5+ years
Are you wearing: None Heel lifts Sole lifts Inner soles Arch supports Age of mattress: <6months 1year 2years 2+yrs OLD ???? Is it comfortable? Y N

Women Only: Are you taking birth control? Y N Are you pregnant? Y N Nursing? Y N

New Patient Form 3 of 4
Alexandria Chiropractic Center