Medical History Form

Date of InjuryDiagnosis as stated by your PhysicianHow did this injury occur?Have you ever been hospitalized for this condition?If yes, what date?Have you ever had surgery for this condition?If yes, what date?Are you taking any medications? Please list them below

Have you ever, or are you presently being treated, for any of the following conditions?

Acquired Respiratory Distress SyndromeAnginaAnxiety of Panic DisordersArthritis (RA, OA)AsthmaChronic Obstructive Pulmonary Disease (COPD)Congestive Heart Failure (CHF)Degenerative Disc DiseaseDepressionDiabetesEmphysemaHearing Loss or DeafnessHeart AttackMultiple SclerosisOsteoporosisParkinsons DiseasePeripheral Vascular DiseaseStroke or TIAUpper Gastrointestinal DiseaseVisual ImpairmentAllergiesHeadachesBleeding DisordersBowel / Bladder AbnormalitiesCancerDizzy or Fainting SpellsEpilepsy or Seizure DisorderFractureHepatitis A, B, or CHerniaHigh Blood PressureHIV / AIDSHypoglycemiaImmunosuppressant Condition or MedicationKidney ProblemsLiver / Gallbladder ProblemsMetal ImplantsNausea / VomitingPacemakerPregnancyRinging in Your EarsSexual DysfunctionSmokingSkin AbnormalitiesTuberculosis

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