Medical History

Center of Movement

Patient Name

Date of Birth

Today's Date

Medical Conditions

Select any conditions you have been diagnosed with.

DiabetesHypertension (high blood pressure)Heart diseaseAsthma / COPDArthritisCancerThyroid disorderAutoimmune conditionNeurological conditionDepression / AnxietySeizure disorderKidney diseaseLiver diseaseBlood clotting disorder

Other conditions not listed

Surgical History

Previous surgeries (leave blank if none)

Hospitalizations

Previous hospitalizations (leave blank if none)

Current Medications

Prescription medications (leave blank if none)

Over-the-counter medications and supplements (leave blank if none)

Allergies

Select all that applyNo known allergiesPenicillin / AmoxicillinSulfa drugsNSAIDs (ibuprofen, aspirin)LatexIodine / Contrast dyeLocal anesthetics (lidocaine)Adhesive / TapeFood allergiesEnvironmental allergies

Describe reactions

Family History

Select conditions that run in your immediate family (parents, siblings, grandparents).

Heart diseaseStrokeCancerDiabetesAutoimmune diseaseOsteoporosisNeurological disease

Details (optional)

Social History

Occupation / Field of Study

Sport (if applicable)

Hobbies & Recreational Activities

Exercise Habits

Cardiovascular exercise

Types of cardio (if applicable)

Resistance / strength training

Types of resistance training (if applicable)

Tobacco use

Alcohol use

Sleep quality

Center of Movement

Salt Lake City, Utah

Opening Summer 2026

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Content on this website is for educational purposes only and does not constitute medical advice. No doctor-patient relationship is established by using this site. See our Terms of Use and Privacy Notice.