Johanna M. Hoeller, DC PS

Transcription

1 ENTRANCE FORM Birth date: Height: Weight: Emergency Contact: Emergency Contact Phone: ( ) Spouse/Partner or Parent s name: Children s names: Occupation (Your): Employer: Address: City/State/Zip: Phone: ( ) Have you experienced any of the following: Recent Fall: Yes No Recent Surgery: Yes No o Type of surgery: Recent motor vehicle accident: Yes No Recent work related accident: Yes No Expectations: _ Referred by: Prior Chiropractic Care: Yes No If yes, who? Medical Doctor: Phone:( ) Address: Date of Last Appointment: Date of Last Physical: (02-12) 4345 Roosevelt Way NE, Seattle, WA Tel

2 Please draw the location of your pain or discomfort on the images below. Use the symbols shown to represent the type(s) of pain: D = Dull S = Stabbing/Sharp B = Burning T = Tingling (Pins & Needles) N = Numb C = Cramping Please reflect on your sense of well-being, taking into account your physical, mental, emotional, social, and spiritual condition over the past month. Use an X on the line to mark your answer to the question. Mark the line below with an X at the point that summarizes your overall sense of well-being for the past month. Worst you have ever been Best you have ever been (02-12) 4345 Roosevelt Way NE, Seattle, WA Tel

3 When (# of months or years) did you first start experiencing this issue? Why did this begin? You experience this issue: Constantly Daily Weekly Monthly Irregularly (explain) When present, how long does it last (give a number or range)? Hours Days Vary (explain) What area is involved: Please describe as: Ache Stiff Tight Spasm Sharp Numbness or other (list) Are there things that make the condition: Better? Worse: On the scales below, please draw vertical lines (intersecting the horizontal lines) that represent the level of discomfort you have at the specified times: Rate the pain you have right now: Rate your pain at its best in the past week: No Pain Unbearable Pain No Pain Unbearable Pain Rate your average pain in the last week: Rate your worst pain in the past week: No Pain Unbearable Pain No Pain Unbearable Pain Patient s Comments: Doctor s Comments: (02-12) 4345 Roosevelt Way NE, Seattle, WA Tel

4 PATIENT HISTORY FORM Please check the appropriate box for any of the following symptoms that you have had within the last year. C = Constant F = Frequent (weekly) O = Occasional (monthly/yearly) C F O C F O C F O NEUROLOGICAL SKIN allergy sinus infections boils chills enlarged glands bruise easily convulsions enlarged thyroid dryness dizziness sore throat hives or allergy fainting tonsillitis itching fevers eye pain skin rash headaches failing vision varicose veins loss of sleep far sighted nervousness gum trouble GENITO-URINARY depression hay fever bed wetting neuralgia hoarseness blood in urine numbness nasal obstruction frequent urination sweats near sighted loss control urine loss of weight nosebleeds kidney infection tremors painful urination CARDIO-VASCULAR prostate trouble MUSCLE & JOINT rapid heart beats pus in urine arthritis slow heart beats smell of urine bursitis swelling of ankle foot trouble hardening of arteries PAIN OR NUMBNESS IN: hernia high blood pressure shoulders low back pain low blood pressure arms neck pain pain over heart hands neck stiffness poor circulation hips pain between shoulders legs knees GASTRO INTESTINAL ankles RESPIRATORY excessive hunger feet chest pain burping or gas painful tail bone chronic cough liver trouble sciatica difficulty breathing colitis swollen joints spitting blood colon trouble throat phlegm constipation FOR WOMEN ONLY wheezing diarrhea cramps difficult digestion heavy flow EYES, EARS, NOSE & distension of abdomen light flow THROAT stomach pain irregular cycle colds gall bladder trouble painful cycle crossed eyes hemorrhoids discharge deafness intestinal worms sore breasts chest pain burping or gas painful tail bone dental decay jaundice asthma poor appetite ear aches nausea ear noises vomiting vomit blood (02-12) 4345 Roosevelt Way NE, Seattle, WA Tel

5 PATIENT HISTORY FORM continued Do you exercise: Yes No If so, describe: Do you wake rested: Yes No Do you feel overly fatigued during the course of the day: Yes No Rate your appetite: Poor Fair Medium Good Excellent Significant Falls and Accidents, list: Have you ever been knocked unconscious: Yes No Don t know If so, for how long: Surgery and Operations, list: List vitamins and minerals that you take: List any medication (dosage/frequency) you are currently taking: Have you previously been hospitalized: Yes No Reason: Any family health conditions or problems: Yes No Please list: Menopausal: Yes No Last menstruation date: Pregnant: Yes No Due date: Patient or parent signature: Date: (02-12) 4345 Roosevelt Way NE, Seattle, WA Tel

6 PATIENT ENTRANCE FORM Medical Specialist DIAGNOSTIC PROCEDURES: Please list X-ray, MRI, CT, and ultrasound studies that have been performed in the past 3 years: Date: Procedure: Area Examined: Results: I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize Dr. Johanna M. Hoeller to release any information, including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such chiropractic care to third party payers and/or health practitioners. Patient or parent signature: Date: (02-12) 4345 Roosevelt Way NE, Seattle, WA Tel