Health History Name: Date: Have you ever had these symptoms before? Yes No Date of injury / Onset: Have you had a related surgery? Yes No Have you ever had or experienced any of the following? Diabetes YesNo Chest pain/ Angina YesNo Heart Disease YesNo Heart Attack YesNo Heart Palpitations YesNo Pace Maker YesNo Headaches YesNo Dizziness/ Fainting YesNo Kidney Problems YesNo Recent Fractures YesNo Blood Disorders YesNo Cancer YesNo OsteoporosisYesNo Multiple Sclerosis YesNo Asthma YesNo Smoking YesNo Mental Disorder YesNo Stroke/ CVA YesNo Glaucoma YesNo Hernia YesNo Seizure YesNo Metal Implants YesNo Rheumatoid Arthritis YesNo Hypoglycemia YesNo Fibromyalgia YesNo Arthritis YesNo Other: Are you currently taking any medication? YES NO ( IF YES PLEASE LIST BELOW) NAME OF MEDICATION DOSE # PER DAY Patient History SURGERIES REASON/ TYPE OF SUGERY DATES ALLERGIES:
