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 Chest pain/ Angina Heart Disease Heart Attack Heart Palpitations Pace Maker Headaches Dizziness Fainting Kidney Problems Recent Fractures Blood Disorders Cancer Osteoporosis Multiple Sclerosis Asthma Smoking Mental Disorder Stroke/ CVA Glaucoma Hernia Seizure Metal Implants Rheumatoid Arthritis Hypoglycemia Fibromyalgia Arthritis 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:
