Medical History Intake Form

All information provided is strictly confidential.

Name *
Preferred Phone *
Preferred Phone
Secondary Phone (optional)
Secondary Phone (optional)
Is the condition getting progressively worse? *
Is this condition interfering with your... *
Has there been a medical diagnosis? *
Have you had a similar problem before? *
Are you on any medications? *
Alcohol intake *
Coffee intake *
Tea Intake *
Tobacco use *
Sugar Intake *
Exercise *
Are you a vegetarian? *
Do you feel you eat a well-balanced diet? *
Are you a shallow breather? *
Have you had any operations/surgeries? *
Have you had any broken bones? *
Have you been in an accident or received a whiplash? *
Please check if you have difficulty with any of the following (there will space at the end of the list to elaborate or clarify): *
CANCELLATION POLICY: All cancellations require a minimum of 24 hours notice. Cancellations or missed appointments for which this office does not receive 24 hours notice are subject to a $75 fee. *