(405) 840-8300
(405) 840-8300

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Medical History

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Check All That Apply

Lung Disease:
Heart Disease:
Stomach Disease:
Bladder Disease:
Liver Disease:
Kidney Disease:
Colon Disease:
Thyroid Disease:
Circulatory Disease:
Mental/Emotional Disorder:
High Blood Pressure:
Low Blood Pressure
Arthritis:
Swollen/Painful Joints:
Recent Weight Loss/Gain
Diabetes:
Seizures/Epilepsy
Cancer:
HIV/AIDS:
Arteriosclerosis:
Polio:
Rheumatic Fever:

Have You Had:

Spinal Exam:
Physical Exam:
Eye Exam:
Chest X-Ray:
Spinal X-Ray:
Dental X-Ray:
Blood Test:
Urine Test:

Frequency

Alcohol:
Coffee:
Tobacco:
Exercise:
Sleep:
Appetite:
Sweets:
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Emergency Contact (Relative or Close Friend not Living in your Home)

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Please do not submit any Protected Health Information (PHI).

Contact Us

We look forward to hearing from you!

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Please do not submit any Protected Health Information (PHI).

Our Location

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Garlett Chiropractic Clinic

Address

4141 Northwest Expy #385
Oklahoma City, OK 73116

Contact Information (405) 840-8300

Office Hours

Monday  

7:00 am - 6:00 pm

Tuesday  

7:00 am - 1:00 pm

Wednesday  

7:00 am - 6:00 pm

Thursday  

7:00 am - 1:00 pm

Friday  

7:00 am - 1:00 pm

Saturday  

Closed

Sunday  

Closed