Medical Information:

1. Date of last physician visit: ___/___/_____ Purpose Of visit:________________

_________________________________________________________________

2. List any medications that you are now taking and the reason for which they were prescribed:__________________________________________________________

___________________________________________________________________

___________________________________________________________________

3. Do you have a chronic illness? ________________________________________

4. Describe your condition: ___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

5. List any procedures, treatments, or surgeries you have undergone: ___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

6. Have you received physical therapy or chiropractic care?__________________________

7. If so, please explain._______________________________________________________

8. Have you or any member of your immediate family been diagnosed with:

Diabetes: __________________ Hypertension: ____________

Stroke: ____________________ Heart Disease: _________________

Obesity: ___________________ Hyperthyroidism: _______________

High Cholesterol: _______________

7. Do you work? Y/ N If yes, how many hours per week? 20 30 40 >40

8. How do you spend most of your time at work?

____Sitting ___Standing ___Carrying loads ____Driving ____Walking

9. Do you smoke? ____Yes ____No

How much, how often: ___________________________________________

10. How many times a week do you engage in moderate to strenuous exercise for at least 30 minutes? ____1 ___2 ___3 ___4 ___5 ___>5

11. Do you have any pain or discomfort while exercising?__________________________

Signature: _________________________________ Date_____/_____/_____

In case of emergency notify the following person:

Name: ___________________________________

Phone: home_______________ Work__________________

Address:_______________________________________________City:__________

State: ________________ Zip: ___________

Signature: ______________________________________________ Date: ______________________