MEDICATION PROFILE & HEALTH QUESTIONNAIRE
NAME: ___________________________
DATE: _______________
Allergies (Food, Medication, Seasonal, etc)
_______________________________________________________________________________
_______________________________________________________________________________
PLEASE LIST ALL PRESCRIPTION AND NON- PRESCRIPTION MEDICATIONS, HOME REMEDIES, SUPPLEMENTS ETC.
DATE
STARTED
DRUG NAME
FREQUENCY
REASON
1. Have you ever broken any bones? Please give details. _____________________________________
________________________________________________________________________________
2. Have you previously been in a car accident, even a low speed car accident? Please give details.
________________________________________________________________________________
________________________________________________________________________________
a. Is there currently an open No Fault claim associated with any accident? YES
NO
b. Have you been treated by a medical doctor or chiropractor for any accidents? YES
NO
3. Have you ever had a surgery (even unrelated to the spine)? Please give details. ________________
________________________________________________________________________________
4. Have you ever received chiropractic treatment before? Where? How long ago? How long did you
receive care? _____________________________________________________________________
________________________________________________________________________________
5. Have you ever consulted a medical doctor for any spinal conditions? Please give details (Dates, Doctor
name and location). ________________________________________________________________
________________________________________________________________________________