Personal Medical History Template
| Allergy | Presently |
|---|---|
| Convulsions | Presently |
| Dizziness | Presently |
| Fainting | Presently |
| Fatigue | Presently |
| Headache | Presently |
| Nervousness | Presently |
| Neuralgia | Presently |
| Numbness | Presently |
| Pain in arms/legs/hands | Presently |
| Backache | Presently |
|---|---|
| Foot trouble | Presently |
| Hernia | Presently |
| Pain between shoulders | Presently |
| Painful tail bone | Presently |
| Stiff neck | Presently |
| Spinal curvature | Presently |
| Swollen joints | Presently |
| Tremors | Presently |
| Twitching | Presently |
| Weakness | Presently |
| High blood pressure | Presently |
|---|---|
| Low blood pressure | Presently |
| Pain over heart | Presently |
| Poor circulation | Presently |
| Previous heart trouble | Presently |
| Stroke | Presently |
| Swelling of ankles | Presently |
| Varicose veins | Presently |
| Chest pain | Presently |
| Chronic cough | Presently |
| Difficulty breathing | Presently |
I hereby authorize the company to examine and treat my condition as deemed appropriate through the use of Chiropractic Care, and give authority for these procedures to be performed. It is understood and agreed the amount paid to the Doctor for Xrays is for examination only and the Xray negatives will remain the property of this office, being on file where they may be seen at any time while a patient of the office. The patient also agrees that he/she is responsible for all bills incurred at this office. The Doctor will not be held responsible for any pre-existing medically diagnosed conditions nor for any medical diagnosis.
Collecting medical data is difficult. If you are working for a massage therapist company and looking for collecting data such as chiropractic information, you can use this Medical Record PDF template. Chiropractic care is a form of alternative medicine that focuses on the relationship between the body's structure, primarily of the spine, and function. With this Medical History Record PDF template, you can pick your patients who are suitable for this treatment.
This Medical History Record PDF template has seven different categories that allow you to collect patients' data such as personal information, family history, and habits like; smoking, coffee and alcohol, general symptoms, muscles and joints, cardiovascular symptoms, and the patient operations and procedures of the past years. Also, to help keep patient data safer, you can opt in to one of our HIPAA-friendly plans.
Patient Medical Record Template
Medical History Record PDF template lets you collect the patient's data such as personal information, contact information in an emergency case, general medical history. By using this sample, the doctor ensures the patient's better care and treatment.
Short Medical History
Medical History Record PDF template is mostly used in order to provide significant information about the health history, care requirements, and risk factors of the patient to doctors. It is for collecting data from the patients.
COVID-19 Vaccine Administration Record
Keep track of patient vaccination records online. More secure with GDPR, CCPA, and optional HIPAA compliance features. Download or print as PDFs. Free, easy-to-customize template.
Professional Medical History Template
Medical History Record PDF template is here to help you in order to know the patient's case and previous condition. You can collect data about the patient and medical background with this Medical History Record PDF sample.
Dietary Requirements Template
Collect important information about food restrictions and allergies. Save submissions as PDFs. Easy to customize, download, print, and share with kitchen staff.
Child Medical History Template
This child medical history PDF template makes checking patients vitals and recording that important data easy. Add your own branding, adjust fields for your specific needs and then simply print out your PDF for the patient's file.
These templates are suggested forms only. If you're using a form as a contract, or to gather personal (or personal health) info, or for some other purpose with legal implications, we recommend that you do your homework to ensure you are complying with applicable laws and that you consult an attorney before relying on any particular form.