Clinical Screening

Medical History Template

The purpose of this form is to understand your past and present medical history. Please don't leave any section blank — type 'no' or 'n/a' if not applicable, or select 'none of the above'.

Patient Information

First Name *

Last Name *

Date of Birth *

Primary Complaint / Aggravating & Relieving Factors / Onset date *

Secondary Complaint / Aggravating & Relieving Factors / Onset date

Current Medications / Dosages *

Primary Care Physician *

Height / Weight *

Please mark if you previously suffered from these conditions *

Addictions *

Cancer? What Type? *

Hospitalizations, Operations and Significant Traumas (with month/year) *

Patient Signature

Signature (typed name) *

Date *

Medical History Template

Patient Information

Past Medical History

Family Medical History

Lifestyle

Current State of Health

Musculoskeletal & Neuropsychological

Previous Treatment

Patient Signature