Health History - Bagnell Solutions 2023
Please complete our initial health history form so that we can better serve you in our office.
(Note: Please type N/A in sections that don't apply). It is important to note that we may contact you, if necessary, regarding areas that are not completed fully, in order to provide you with the best care possible.
NEW PATIENTS ONLY: If you do not receive a follow-up email within 24 business hours, please contact our office to confirm we have received your Health History Form.
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Pregnant Patients: MUST COMPLETE this FORM
Children 12 and under: MUST COMPLETE this FORM
Patient's Full Name: (First, Middle, Last,)
Date of Birth:
Phone number (best contact):
Primary Insurance Company Name:
Primary Insurance - Policy ID:
Primary Insurance - Policy Group Number: (if none then type: 000)
Secondary Insurance Company Name (If Applicable):
Secondary Insurance - Policy ID (If Applicable):
Secondary Insurance - Policy Group Number (If Applicable):
Insurance Policy Holder's Name:
Insurance Policy Holder's Date of Birth:
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:
High Blood Pressure
History of Smoking
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?
Auto Accident (s)
Motorcycle Accident (s)
Fall Down Stairs
Slip on Ice
Fallen off a Horse or Bicycle
Falls of any kind not mentioned
Did the trauma happen within:
Past 5 years
Over 5 years
Medications and/or supplements currently taking:
High Blood pressure meds
Have you tested positive for Coronavirus?
Have you had a temperature above 100.4 F within the past 2 weeks? (If "Yes" please explain)
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