PATIENT HISTORY QUESTIONNAIRE
Patient Name:					Date of Birth:
Primary Care Physician:
Allergies and Allergy Reactions:
List of Medications (dosage):
List Previous Accident / Injury / Surgeries (dates)
Please check appropriate box in each section below:
	Yes	No	If yes, how long?			Yes	No	If yes, how long?
Neck pain				Rheumatoid arthritis
Upper back pain				Osteoarthritis
Lower back pain				Chronic pain treatment
Shoulder pain (R/L)				Stroke
Hip pain ( R/L)				Multiple sclerosis
Elbow pain (R/L)				Paralysis
Hand pain (R/L)				Muscle weakness
Wrist pain (R/L)				Fainting
Headache (R/L)				Numbness
Jaw Pain (R/L)
Hypertension				Asthma
Heart attack			Date:	COPD
Diabetes				Pneumonia
Angina				TB
High cholesterol				Chronic cough
Poor circulation				Sleep apnea
Gastric Reflex				Kidney Stone
Gastric Ulcer				Urinary tract infection
Hiatal hernia				Prostate disease
Hepatitis A, B or C				Dialysis
Do you drink?				Pregnancy?
Do you use drugs?				Cancer?
Do you smoke?				Location of cancer:
				Date:
(Patient/Parent/Conservator/Guardian)					(If completed by other than patient, relationship)