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Medical History

If you are a new patient and have not filled out a Medical History, please fill out the form below.

Patients cannot proceed to their appointment without a completed history form.

Thank You!

Name *

First Name

Last Name

Phone

(###)

###

####

Email *

Cause of the Current Issue: *

Car Accident

Work Injury

Gradual Onset

Other

Have you ever had a Workers' Compensation or No-Fault related injury in your life-time? If so, when and which body parts were affected? *

Do you have a history of any of the following issues? *

High Blood Pressure

Heart Disease

Stroke

Heart Attack

Diabetes

Asthma

Sleep Apnea

Depression

Anxiety

Bipolar Disorder

Kidney Disease

Thyroid Disease

Migraines

Cancer

None

List any medications you are currently taking (prescription & over-the-counter): *

Please include dosage and reason for taking this medication. If you are not currently taking any medications, type "none" in the space provided below.

Do you have any of the following allergies? *

If you selected "other", please explain in the space provided below.

Latex

Penicillin

Codeine

Sulfa Antibiotics

Other

None

List any surgeries that you have had in your lifetime: *

Please provide the approximate date of the surgery and be as specific as possible.

Do you have any complications with anesthesia that you are aware of? *

If you answered yes, please explain.

Have you been in the hospital for more than 24 hours in the last year? *

If so, please explain.

Are you currently seeing any of the following specialists? *

Primary Care Doctor

Chiropractor

Pain Management

Physical Therapy/Massage Therapy

Neurologist

Other

None

Please list the name(s) of the specialists you are currently seeing:

Did any of the specialists above refer you? *

If so, please provide us with their name in the space below.

Do you use any of the following devices on a regular or as needed basis? *

Select all that apply.

Glasses

Contacts

Hearing Aids

Cane

Walker

Wheelchair

Back Brace

Neck Brace

TENS Unit

None

Any car accidents or work related injuries? If so, please include which body parts were injured & date of the accident *

Please explain.

Does anyone in the immediate family have any medical problems like high blood pressure, diabetes, etc…? *

If so, please explain.

Are your parents currently living? *

If so, how old are they and do they have any prominent medical issues?

If deceased, how did your parents pass away?

Do you have any children? *

If so, how many?

Do you have any siblings? *

If so, how many?

What is your marital status? *

Who do you live with? *

What is your highest level of education? *

What is your occupation? *

What is your work status?

Full Time Employment

Part-Time

Retired

Unemployed

Other

Which hand is your dominant hand?

Any smoking, alcohol, or drug use? *

Thank you!

Stay Connected with reVive Spine Center

First Name

Last Name

Email Address

By signing up, you agree to allowing us to send emails regarding news, updates, and review requests. Your data is held under HIPAA compliance and is never sold to third-party companies.

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ReVive Spine Center
716-55-SPINE

Disclaimer:

The information provided in all content of this website is intended for your general knowledge only and is not a substitute for professional medical advice, diagnosis, or treatment of specific medical conditions. You should not use this information to diagnose or treat a health problem or disease without consulting with a qualified healthcare provider. Please consult your healthcare provider with regard to any conditions, treatments, questions, or concerns you may have regarding your condition. Since every patient is different, the results achieved by any particular patient, or with respect to the treatment of any particular condition, cannot be guaranteed or assured.