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Health History Questionnaire

Name

Patient Name (please print)*

Birthday*

Month

Day

Year

Have you ever had any of the following?

Any illness or injury in the last 5 years?*

Yes

No

Head/brain injuries, disorders or illnesses?*

Yes

No

Seizures/epilepsy?*

Yes

No

Eye disorders or impaired vision?*

Yes

No

Ear disorders, loss of hearing, or loss of balance?*

Yes

No

Heart disease, heart attack, or other cardiovascular condition?*

Yes

No

Heart surgery (valve replacement/bypass/angioplasty/pacemaker)?*

Yes

No

High blood pressure?*

Yes

No

Muscular disease?*

Yes

No

Shortness of breath?*

Yes

No

Lung disease, emphysema, asthma, chronic bronchitis, etc?*

Yes

No

Kidney disease/dialysis?*

Yes

No

Liver disease?*

Yes

No

Digestive problems?*

Yes

No

Diabetes or elevated blood sugar?*

Yes

No

Nervous or psychiatric disorders?*

Yes

No

Loss of consciousness?*

Yes

No

Fainting or dizziness?*

Yes

No

Sleep disorders?*

Yes

No

Stroke or paralysis?*

Yes

No

Missing or impaired hand, arm, foot, leg, finger, or toe?*

Yes

No

Spinal injury or disease?*

Yes

No

Chronic low back pain?*

Yes

No

Regular/frequent alcohol use?*

Yes

No

Narcotic or habit-forming drug use?*

Yes

No

List any medications you are taking:*

List any surgeries you have had:*

Patient Signature*

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Date*

Month

Day

Year

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