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Health History - Bagnell Solutions 2023
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
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Email
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Your email
Pregnant Patients: MUST COMPLETE this FORM
https://forms.gle/ecdT3yHBshUtYguL8
Children 12 and under: MUST COMPLETE this FORM
https://forms.gle/rFCa1mnshWRCEzoP9
Patient's Full Name: (First, Middle, Last,)
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Your answer
Date of Birth:
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Your answer
Age:
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Your answer
Gender:
Choose
Female
Male
Address:
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Your answer
City:
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Your answer
State:
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Your answer
Zip Code:
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Your answer
Phone number (best contact):
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Your answer
Occupation:
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Your answer
Primary Insurance Company Name:
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Your answer
Primary Insurance - Policy ID:
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Your answer
Primary Insurance - Policy Group Number: (if none then type: 000)
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Your answer
Secondary Insurance Company Name (If Applicable):
Your answer
Secondary Insurance - Policy ID (If Applicable):
Your answer
Secondary Insurance - Policy Group Number (If Applicable):
Your answer
Martial Status:
Choose
Single
Married
Separated
Divorced
Widowed
Domestic Union
Insurance Policy Holder's Name:
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Your answer
Insurance Policy Holder's Date of Birth:
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Your answer
Whom may we thank for referring you?
Your answer
How did you find out about our office?
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Your answer
Have you seen a Chiropractor before (yes)? What for?
Your answer
Have you seen a Medical Doctor for this current condition?
Yes
No
Clear selection
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:
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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
Other:
Required
Explain Medical history from previous question? (List fractures, surgeries, heart, lung, reproductive issues, cancer, diabetes, high blood pressure, arthritis, N/A, etc.)
Your answer
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
Other:
Did the trauma happen within:
Past year
Past 5 years
Over 5 years
Never
Other:
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
Other:
Have you tested positive for Coronavirus?
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Yes
No
Required
Have you had a temperature above 100.4 F within the past 2 weeks? (If "Yes" please explain)
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Your answer
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