APPOINTMENT – R6 Spinal Treatment

R6 Spinal Treatment

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Name

Email

Date

Time

Phone

Email

Address

Occupation

Age

DOB

Chief Complaint

Allergies (Drug and Other)

Current Medications

Family History

Heart Disease

Father Mother Father’s Parents Mother’s Parents Siblings Children

High Blood Pressure

Father Mother Father’s Parents Mother’s Parents Siblings Children

Stroke

Father Mother Father’s Parents Mother’s Parents Siblings Children

Cancer

Father Mother Father’s Parents Mother’s Parents Siblings Children

Glaucoma

Father Mother Father’s Parents Mother’s Parents Siblings Children

Diabetes

Father Mother Father’s Parents Mother’s Parents Siblings Children

Epilepsy/Convulsions

Father Mother Father’s Parents Mother’s Parents Siblings Children

Bleeding Disorder

Father Mother Father’s Parents Mother’s Parents Siblings Children

Kidney Disease

Father Mother Father’s Parents Mother’s Parents Siblings Children

Thyroid Disease

Father Mother Father’s Parents Mother’s Parents Siblings Children

Mental Illness

Father Mother Father’s Parents Mother’s Parents Siblings Children

Osteoporosis

Father Mother Father’s Parents Mother’s Parents Siblings Children

Hospitalization or Surgery

Reason

Date

Reason

Date

Medical History

Hypertension Dizziness/Fainting Ulcer Anxiety Hyperlipidemia GI disorder Heart palpitations Fatigue Sexual dysfunction Heart murmur Anemia Allergies/Hay fever Chest pain/Angina Incontinence Orthopnea Shortness of breath Arrhythmia Incontinence MI COPD Gout Pneumonia Claudication Osteoporosis Stroke/TIAs Arthritis Asthma Congestive heart failure Venereal disease Diabetes Congenital heart disease Scarlet fever Endocrine disease Headache Rheumatic fever Epilepsy

Women Only

Pregnant?

Yes No

Planning Pregnant?

Yes No

Men Only

It’s common for men to occasionally experience erection difficulties. Is this something that happens to you?

Yes No

Do you occasionally experience erection difficulties?

Yes No

Habits

Smoking

Yes No

Packs daily

How Long?

Interesting in stopping?

Coffee

Yes No

Cups daily

Other caffeine

Alcohol

Yes No

Type

Sleep

Yes No

Difficulty falling asleep

Difficulty staying asleep

Snoring

Company

R-6 Spine Treatment
Phone: 202-652-0536

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