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New Family Health History Form.xls - The Brooks Chiropractic

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New Family Health History Form.xls - The Brooks Chiropractic Powered By Docstoc
					                             FAMILY HEALTH HISTORY
Patient:
                 Please review the below-listed diseases and indicate those that are current
    health problems of a family member. Leave blank those space that do not apply. If you require more
                                  space, use the reverse side of this form.
                     FATHER MOTHER SPOUSE BROTHER(S)                             SISTER(S)         CHILDREN
CONDITION            AGE:        AGE         AGE:      AGE[ ] AGE[ ] AGE[ ] AGE[ ] AGE[ ] AGE[ ]
Arthritis                                                                                          AGE[ ]
Asthma-Hay Fever
Back Trouble
Bursitis
Cancer
Constipation
Diabetes
Disc Problem
Emphysema
Epilepsy
Headaches
Heart Trouble
High Blood Pressure
Insomnia
Kidney Trouble
Liver Trouble
Migraines
Nervousness
Neuritis
Neuralgia
Pinched Nerve
Scoliosis
Sinus Trouble
Stomach Trouble
Other


                        INFORMED PATIENT CONSENT
 I UNDERSTAND THAT IF I AM ACCEPTED AS A PATIENT OF BROOKS CHIROPRACTIC AND WELLNESS
    CLINIC, I AM AUTHORIZING THEM TO PROCEED WITH ANY FURTHER TREATMENT THAT MAY BE
NECESSARY. FURTHERMORE, ANY RISKS INVOLVING CHIROPRACTIC TREATMENT WILL BE EXPLAINED
                                   TO ME UPON REQUEST.




PATIENT SIGNATURE:                                                             DATE



PARENT/GAURDIAN AUTHORIZING CARE                                               DATE




                             BROOKS CHIROPRACTIC AND WELLNESS CLINIC
                                      1032 S. SPRING STREET
                                   PORT WASHINGTON, WI 53074

				
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posted:5/9/2014
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