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.
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.
Veterinary Hospital Treatment Sheet Template
Veterinary Hospital Treatment Sheet helps both the hospital and pet owners in understanding and tracking a pet's treatment process. Just like any other hospitals, keeping patient's treatment records is necessary to monitor progress and make sure proper treatment is given. Having a veterinary treatment sheet also helps in planning and evaluating other treatments for the pet, facilitating research and creating a record for the pet's future care. If you are trying to create a treatment sheet and looking for a sample template, then look no further because Jotform offers a Veterinary Hospital Treatment Sheet template you can download, save, edit and print. This Veterinary Treatment Sheet template contains the necessary information for recording and tracking treatment process for your client's pet. It has information such as name of client, date and time, address, contact number, treatment performed, doctor's name, monitoring progress report and many more. This template is editable and allows you to add more information or remove if you need to. Add your hospital's logo or insert images to make it more personalized.
Dental Health Record Template
The Dental Health Record Template is easy for patients to fill out and designed to get the doctor the most important information. Patients can fill out their information on a computer or tablet using our Dental Health Record Template.
Patient Medical History Template
Through Medical History Record PDF template, patients provide their personal information needed to see the doctor. Thanks to this medical history record sample, the doctor knows about patients medical history.
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.
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.
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.