您的浏览器中未启用 JavaScript,因此无法打开此文件。请启用 JavaScript,然后重新加载。
Health History - Bagnell Solutions 2022
Please complete our initial health history form so that we can better serve you in our office.
(Note: Please type N/A in sections that don't apply). It is important to note that we may contact you, if necessary, regarding areas that are not completed fully, in order to provide you with the best care possible.
NEW PATIENTS ONLY: If you do not receive a follow-up email within 24 business hours, please contact our office to confirm we have received your Health History Form.
Thank you.
(215) 504-2711
You DO NOT have to sign into Google to complete this form.
Start by entering your email address.
登录 Google
即可保存进度。
了解详情
* 表示必填
电子邮件地址
*
您的电子邮件
Pregnant Patients: MUST COMPLETE this FORM
https://forms.gle/FofTJWJsMiMFnGXG9
Children 12 and under: MUST COMPLETE this FORM
https://forms.gle/ju1GEweHsV291Zr96
Patient's Full Name: (First, Middle, Last,)
*
您的回答
Date of Birth:
*
您的回答
Age:
*
您的回答
Gender:
选择
Female
Male
Address:
*
您的回答
City:
*
您的回答
State:
*
您的回答
Zip Code:
*
您的回答
Phone number (best contact):
*
您的回答
Occupation:
*
您的回答
Primary Insurance Company Name:
*
您的回答
Primary Insurance - Policy ID:
*
您的回答
Primary Insurance - Policy Group Number:
*
您的回答
Secondary Insurance Company Name (If Applicable):
您的回答
Secondary Insurance - Policy ID (If Applicable):
您的回答
Secondary Insurance - Policy Group Number (If Applicable):
您的回答
Martial Status:
选择
Single
Married
Separated
Divorced
Widowed
Domestic Union
Insurance Policy Holder's Name:
*
您的回答
Insurance Policy Holder's Date of Birth:
*
您的回答
Whom may we thank for referring you?
您的回答
How did you find out about our office?
*
您的回答
Have you seen a Chiropractor before (yes)? What for?
您的回答
Have you seen a Medical Doctor for this current condition?
Yes
No
清除所选内容
Diagnostic Test Performed
If you have had any diagnostic testing performed for your current condition, please bring any and all images, reports, CDs or any information to your appointment.
(Medical History) Have you ever suffered from:
*
Dizziness
Backaches
Diabetes
Heart Trouble
High Blood Pressure
Headaches
Asthma
Stomach Trouble
Sinus Trouble
Arthritis
Liver Problems
Bowel Issues
Fractures
Cancer
Reproductive Issues
Allergies
History of Smoking
None
其他:
必填
Explain Medical history from previous question? (List fractures, surgeries, heart, lung, reproductive issues, cancer, diabetes, high blood pressure, arthritis, N/A, etc.)
您的回答
Have you ever been in or have had any of the following traumas?
Auto Accident (s)
Motorcycle Accident (s)
Fall Down Stairs
Slip on Ice
Fallen off a Horse or Bicycle
Falls of any kind not mentioned
Sports Injuries
Work Injuries
Lifting Injuries
其他:
Did the trauma happen within:
Past year
Past 5 years
Over 5 years
Never
其他:
Medications and/or supplements currently taking:
Nerve pills
Pain killers
Muscle relaxers
Tranquilizers
Insulin
Birth control
High Blood pressure meds
Cholesterol meds
Diuretics'
Nutritional supplements
其他:
Have you tested positive for Coronavirus?
*
Yes
No
必填
Have you had a temperature above 100.4 F within the past 2 weeks? (If "Yes" please explain)
*
您的回答
下一页
清除表单内容
切勿通过 Google 表单提交密码。
此内容不是由 Google 所创建,Google 不对其作任何担保。
举报滥用行为
-
服务条款
-
隐私权政策
表单