NEW PATIENT INFORMATION

Transcription

1 NEW PATIENT INFORMATION PATIENT INFORMATION First Name: Middle Initial: Last Name: Sex Male Female Date of Birth: Age: SSN: Marital Status: Married Single Divorced Widowed Number of Children: Home Phone: Work Phone: Mobile Phone: Home Address: City: State: Zip: Address: Occupation: Who may we thank for referring you? INSURANCE INFORMATION Insurance: Group ID#: Member ID#: Insurance Subscriber: Date of Birth: Relationship to Patient: Subscriber Employer: MEDICAL INFORMATION FOR WOMEN ONLY Are you pregnant? Yes No Possible/Unknown If pregnant, due date: Name of OBGYN or Midwife: If x-rays are recommended, your signature is required to indicate that you are not pregnant. Signature: Date: ALLERGIES (CIRCLE ALL THAT APP LY) Animals Dust Ragweed/Pollen Wheat Aspirin Eggs Rubber X-Ray Dye Bee Latex Seasonal Allergies Chocolate Molds Shellfish Dairy Penicillin Soap Other: PAST PHYSICAL TRAUMAS/SURGERIES Were you born at home or in a hospital? Medication used? Yes No C-Section: Yes No Forceps/Vacuum: Yes No Did you have any significant childhood injuries? (fractures, stitches, falls, sports-related, etc.) Please list dates, injury and treatment: Have you had any significant adult injuries? Please list dates, injury and treatment: Please list any surgeries: Have you had any automobile accidents or work-related injuries? Page 1

2 EMOTIONAL STRESS Please indicate if you have experienced any of the emotional stresses below: Childhood trauma Y N Loss of loved one Y N Work or school Y N Divorce/separation Y N Lifestyle change Y N Parents divorce Y N Abuse Y N Financial Y N Illness Y N CURRENT PHYSICAL STRESS Please describe your usual work position and how long you maintain it during the day. For example, do you work at a computer, talk on the phone or stand at a machine for most of the day? Does your job require airline travel and hotel stays? Y N If yes, how often? How long is your daily commute? How many hours do you typically work in a week? How many hours per week do you watch T.V.? Are you sitting or lying on a couch? Please describe your exercise/sports program including type and frequency: How many hours of sleep do you typically get each night? Do you sleep well? Y N Do you ever sleep on your stomach? Y N How old is your mattress? Do you wear orthotics (foot supports) or a heel lift? Y N If yes, how many years? Do you use a cervical pillow? Y N CHEMICAL STRESS Chemical stress can occur when a substance, that is toxic to the body, is breathed, injected, taken by mouth, or placed on the skin (e.g., food allergies, drug reactions, exposure to chemicals in the air, etc.). The following will reveal exposures you may have had. Were you vaccinated? Y N If yes, did you have a reaction? Y N Have you been exposed to any of the following on a regular basis, past or present? Toxic Chemicals Radiation If yes, please explain: Second hand smoke Chemotherapy Drug therapy Other Do you have any food allergies? Y N If yes, please list: How many fast food meals do you eat per week? How many alcoholic beverages do you drink per week? Do you use tobacco products? Y N If yes, what type? How often: How many glasses of water do you drink per day? How many caffeinated beverages (coffee, tea, soda) do you drink per day? Are you currently on prescription or over-the-counter medication? Y N Please list, indicating dose & frequency Page 2

3 Please list any nutritional suppliments you are taking: Do you exercise? If yes, what forms and how often: How do you rate your physical? Excellent Good Fair Poor FAMILY HISTORY (PLEASE INDICATE MAT ERNAL M OR PATERNAL P SIDES OF THE FAMILY OR SIBLING S ) Do you have a family history of: M P S Arthritis M P S Asthma M P S Back Pain M P S Cancer M P S Depression M P S Diabetes M P S Epilepsy M P S Heart Problems M P S High Blood Pressure M P S Neurological Problems M P S Parkinson s M P S Polio M P S Prostate Problems M P S Stroke/Heart Attack M P S Genetic Spinal Condition HEALTHCARE PRACTITIONER HISTORY Have you ever received Chiropractic care? Yes No Name of DC: How long under care: days weeks months years Date of last visit: Why did you stop? How was your experience? Have you consulted, or do you regularly consult, any of the following providers? (Check all that apply.) Medical Physician Naturopath Homeopath Acupuncturist Massage Therapist Psychotherapist Energy Healer Dentist QUALITY OF LIFE What number best describes how you feel your today? What number best describes how you would like to feel in the future? serious concerns overall worried constant concerns that affect challenge s that affect me on a daily basis some minor complain ts ok with no complaints good most days well on a daily basis energeti c and y active, energ etic and fit great and am proactive Page 3

4 MEDICAL HISTORY (PLEASE LIST PAST AND CURRENT CONDITIONS ) Please place an X on conditions that you are currently suffering from and an O on any conditions you have had in the past. Pain & Inflammation Metabolism/Energy Cognitive Health Detoxification Ankle Pain Fatigue Anxiety Disorder Kidney Problems Arm Pain Loss of Balance Convulsions/Epilepsy Liver Problems Chest Pain Significant Weight Gain Depression Skin Problems Elbow Pain Male Health Dizziness Foot Pain Impotence Eating Disorder Sensory Health Hand Pain Prostate Problems Headaches Eye/Vision Problems Hip Pain Frequent Urination Learning Disbility Hearing Problems Jaw Pain Female Health Memory Loss Knee Pain Menopausal Problems Mental/Emotional Issues Blood Sugar Maintenance Leg Pain Menstrual Problems Neurological Problems Diabetes Neck Pain/Stiffness Frequent Urination Numbness/Tingling Arms & Hands Sprain/Strain Injury Digestive Health Numbness/Tingling Legs & Feet Fainting Immunity Mid-back Pain Constipation/Diarrhea Parkinson s Frequent Colds/Flu Shoulder Pain Digestive Problems Stroke Ear Infection Pain with cough or strain Gas - excessive Trouble Concentrating HIV Back Pain/Stiffness Constipation/Diarrhea Trouble Sleeping Cardiovascular Health Low Middle Upper Gall Bladder Respiratory Health Blood Pressure (low/high) Liver Asthma Bruise Easily Hepatitis Difficulty Breathing Heart Attack Allergies Bone & Joint Health Heart Problems Arthritis Broken Bones Joint Stiffness High Blood Pressure Multiple Sclerosis Carpel Tunnel Syndrome Spinal Cord Injury Minor Health Problem Polio Genetic Spinal Condition Pacemaker Page 4

5 EXPECTATIONS/CURRENT CONDITIONS Main Reason for consulting the office: Become pain free Explanation of condition Learn how to care for condition Reduce symptoms Resume normal activity level Please mark your areas of symptoms on diagram below Describe your symptoms: Describe nature of your symptoms: Ache Burning Numb Radiating Pain Sharp Shooting Stabbing Tightness Tingling Other: Date your symptoms began: How did this begin (fall, lifting, etc.)? How are your symptoms changing? Getting better Getting worse Not changing Have you had these symptoms in the past? Yes No How often do you experience your symptoms? Constantly (76-100% of the day) Frequently (51-75% of the day) Occasionally (26-50% of the day) Intermittently (0-25% of the day) Please rate your pain on a scale of 0 to 10: No Pain Excruciating Pain How do your symptoms affect your ability to perform daily activities such as working or driving? No interference Unable to carry out activity What activities make your symptoms WORSE (working, exercise, bending, etc.)? What activities make your symptoms BETTER (ice, heat, massage, etc.)? Signature: For Office Use Only: Vitals: Height: Weight: Blood Pressure: Date: Page 5