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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.

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Name *

First Name

Last Name

Phone *

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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

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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.