Patient History Questionnaire

Please take a moment to fill out this form. Your responses will help us understand your health needs and provide the best care possible. If you have any questions, please contact us (213) 915-0300

Patient Name *

Phone Number *

Email *

How did you hear about us? *

Reason for visit *

Pain Scale: Please rate your discomfort on a scale of 0 to 10: *



Have you seen any doctors or had any tests done for your condition? *

Have you received any treatments for your condition? *

I feel happiest when I can do these activities:

Please list all current medications and what they’re for: *

Do you have any allergies? *

Please list any surgeries you’ve had (including the year if possible): *

Do you smoke? *
Do you drink alcohol? *

Please rate your level of stress recently: *


Is your pain linked to any specific situation? *

Please check those that apply

What makes your symptoms better?

Hand Dominance:

    General Health *

    Do you have or have you had any of the following?

    (Please check all that apply)

    Neck/Head Issues *

    (Please check all that apply)

    Breathing and Sleep *

    (Please check all that apply)

    Vision *

    (Please check all that apply)

    Dental *

    (Please check all that apply)

    History of braces?

    Any other conditions or concerns you would like to mention? *

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