Health History - Bagnell Solutions 2025

We kindly ask you to complete our initial Health History Form to help us provide you with the best possible care in our office. For any sections that do not apply to you, please type "N/A."

Please note that we may reach out if any areas of the form are incomplete to ensure we have the necessary information to serve you effectively.

New Patients Only: If you do not receive a follow-up email or text within 24 business hours, please contact our office to confirm receipt of your Health History Form.

Thank you for your cooperation!


(215) 504-2711

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Email *
Pregnant Patients: MUST COMPLETE this FORM
Pregnant Clients Click Here
Children 12 and under: MUST COMPLETE this FORM
Auto Accident Injuries: MUST COMPLETE this FORM
Phone number (best contact): *
Patient's First Name: (First) *
Middle Name: (Middle) *
Last Name: (Last) *
Age: *
Gender: *
Address: *
City: *
State: *
Zip: *
Occupation: *
Date of Birth: *
Primary Insurance Company Name: *
Primary Insurance - Policy ID: *
Primary Insurance - Policy Group Number: (if none then type: 000) *
Insurance Policy Holder's Name: *
Insurance Policy Holder's Date of Birth: *
Relationship Status: *
Whom may we thank for referring you? *
How did you find out about our office? *
Have you seen a Chiropractor before (yes)? What for? *
Have you seen a Medical Doctor for this current condition? *
Diagnostic Test Performed
If you have had any diagnostic testing performed for your current condition, please bring any and all images, reports, CDs or any information to your appointment.
(Medical History) Have you ever suffered from: *
Required
Explain Medical history from previous question? (List fractures, surgeries, heart, lung, reproductive issues, cancer, diabetes, high blood pressure, arthritis, N/A, etc.) *
Have you ever been in or have had any of the following traumas? *
Required
Did the trauma happen within: *
Required
Medications and/or supplements currently taking: *
Required
Have you had a temperature above 100.4 F within the past 2 weeks? (If "Yes" please explain) *
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