Health History
Name____________________________________________________Date_________________
Age______________________Height______________________Weight___________________
Medications or supplements you currently take ___________________________________________________________________
____________________________________________________________________________________________________________
Do you have any allergies? ____________________________________________________________________________________
Have you had any surgeries? __________________________________________________________________________________
Have you been hospitalized other than described above? ___________________________________________________________
Have you had any major illness other than described above? _______________________________________________________
Have you had any recent medical tests? What were the results? _____________________________________________________
Have you any problems with:
Skin, hair and nails? _________________________________________________________________________________________
Muscles, bones or joints? ______________________________________________________________________________________
Heart, blood or circulation? ___________________________________________________________________________________
Brain, spinal cord or nerves? __________________________________________________________________________________
Lymphatic or immune system? _________________________________________________________________________________
Endocrine glands such as thyroid, adrenal, pituitary? _____________________________________________________________
Sinuses, lungs, breathing? _____________________________________________________________________________________
Teeth, stomach, digestion, elimination, gall bladder, liver, blood sugar? ______________________________________________
Urination, blood pressure, kidneys? ____________________________________________________________________________
Reproductive system including internal organs, external organs and breasts? __________________________________________
Is there anything else you would like the doctor to know?
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Keller Chiropractic
422 Morse Road Columbus Ohio 43214
614-885-4480