Area of Complaint: Right Left Bilateral. When did your complaint begin? Unknown Work Accident Auto Accident Sports Injury Other:
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- Augustus Mathews
- 5 years ago
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1 Quality Chiropractic 6231 Leesburg Pike Suite 200 Falls Church VA (703) fax (703) Quality Chiropractic & Rehab 102 Elden Street Suite 12 Herndon VA (703) fax (703) Name Date PLEASE ANSWER THE FOLLOWING QUESTIONS REGARDING YOUR PRIMARY COMPLAINT Area of Complaint: Right Left Bilateral When did your complaint begin? Have you had this complaint previously? Y (how long ago ) N What happened to cause or re-aggravate your complaint? Unknown Work Accident Auto Accident Sports Injury Other: Have you received any recent treatment for this complaint? Y N If yes, please list dates, treatment type, and doctor Describe your pain: Achy Burning Dull Sharp Stiff Throbbing Stabbing Tightness Tingling Is your pain: Mild Moderate Severe Is the pain: Constant Frequent Intermittent Occasional Does the pain travel anywhere? Have you experienced a change in any of the following since your symptoms began? Bowel Function Bladder Function Sexual Function None What time of the day does it feel worse: Morning Afternoon Evening While sleeping What aggravates your pain? What time of the day does it feel better: Morning Afternoon Evening While sleeping What alleviates your pain? Is there numbness? Y N Where: Is there spasm? Y N Where: Is there any weakness? Y N Where: Is there swelling? Y N Where: 1
2 If your complaint involves headaches, please complete the following: What is the location of your headaches: Front Side Back Sinus What time of day does it feel worse: Morning Afternoon Evening While sleeping How often do they occur: times per: Hour Day Week Month What is the duration of your headaches: Minutes Hours Constant PLEASE ANSWER THE FOLLOWING QUESTIONS REGARDING YOUR SECONDARY COMPLAINT Area of Complaint: Right Left Bilateral When did your complaint begin? Have you had this complaint previously? Y (how long ago ) N What happened to cause or re-aggravate your complaint? Unknown Work Accident Auto Accident Sports Injury Other: Have you received any recent treatment for this complaint? Y N If yes, please list dates, treatment type, and doctor Describe your pain: Achy Burning Dull Sharp Stiff Throbbing Tingling Burning Other Is your pain: Mild Moderate Severe Is the pain: Constant Frequent Intermittent Occasional Does the pain travel anywhere? Have you experienced a change in any of the following since your symptoms began? Bowel Function Bladder Function Sexual Function None What time of the day does it feel worse: Morning Afternoon Evening While sleeping What aggravates your pain? What time of the day does it feel better: Morning Afternoon Evening While sleeping What alleviates your pain? Is there numbness? Y N Where: Is there spasm? Y N Where: Is there any weakness? Y N Where: Is there swelling? Y N Where: 2
3 Mark the area(s) on your body where you feel the described sensation(s). Use the appropriate symbol(s). Numbness Pins & Needles Burning Aching Stabbing oooooooooooo ^^^^^^^ XXXXX //////////////// Please mark any of the following conditions or symptoms that you have now or have experienced previously: O AIDS/HIV O Insomnia O Infections O Polio O Depression/Anxiety O Digestion Problems O Jaw pain/tmj O Sinus condition O Drug Abuse O TB O Dizziness O Anemia O Liver disease O Asthma O Eye/ear disorder O Arthritis O Diabetes O Prostate problems O Cancer O Thyroid disease O High blood pressure O Hernia O Kidney disease O Heart disease O Stroke O Chest pain O Weight loss/gain Please complete the following regarding medications/supplements that you are currently taking. Date Started Vitamin/Drug Name Prescribed by 3
4 Please list any allergies. Allergy Reaction Please list any surgeries. Date (Approximate) Surgery Facility Please list hospitalizations (you can exclude surgery related if listed above.) Date (Approximate) Reason Hospital Please list any pertinent family history. Relationship History Deceased Y/N Father Cause of Death Mother Brothers Sisters Children Paternal Grandparent Maternal Grandparent 4
5 With whom do you currently live with: Alone Spouse Spouse/Children(# ) Other Smoking Status: Current Former Never Alcohol Intake: None Casual Moderate Severe Caffeine Intake: None <3/day 3 to 6/day >6/day Recreational Drugs: None Recreational User Addict Exercise Frequency: None Daily 3-6x/week 1-2x/week Exercise Type: Are you currently: In School Employed (FT or PT) Unemployed Retired What is your occupation? How long have you been at your current job? Do you currently have a Primary Care Physician? Y N Doctor s Name: Have you been to a chiropractor prior to today s visit? Y N Date of your last chiropractic adjustment: Females: to the best of your knowledge are you pregnant? Y N Date of last menstrual period: To the best of my knowledge, all of the information completed above is correct. Signature: Date: 5
Case Number: (For Office Use Only) Social Security #: - - Birthday: - - Social Security#: - - Birthday: - - How did you hear about us?
Date: Name: Case Number: (For Office Use Only) Nickname: Address: City: State: Zip: Social Security #: - - Birthday: - - Spouse s Name: Social Security#: - - Birthday: - - Contact Information Home: - -
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Patient # (assigned by office) Full Name: Social Security # Address: City: State: Zip: address: Home Phone Cell Phone:
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PATIENT HISTORY FORM
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Van Wyk Chiropractic Center Terms of Acceptance and Privacy Policy
Van Wyk Chiropractic Center Terms of Acceptance and Privacy Policy Terms of Acceptance When a patient seeks health care in our office and we accept a patient for such care, it is essential the patient
New Patient Information
(Please Print) New Patient Information Name Address City/State/Zip Cell: Home: email: Social Security # Birthdate Age Male Female Occupation Employed by Wk ph. # Address City/State/Zip Number of Children
Patient s Name Date: Is today s problem caused by: Auto Accident Workman s Compensation Slip and Fall Other
Patient s Name Date: What is the reason for you visit today? Is today s problem caused by: Auto Accident Workman s Compensation Slip and Fall Other Personal Information Address City/State/Zip Phone # (home)
Name Date. Date of Birth Social Security #: Street Address. City State Zip. Home Phone Cell Phone Address. Employer Business Phone
Barcode Label Interviewer: Office: **PLEASE USE BLACK INK** Patient Information Please Print Name Date Date of Birth Social Security #: Street Address City State Zip Home Phone Cell Phone E-Mail Address
SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET
SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET EC#: (for office use only) Patient s Name: Today s Date: Age: Date of Birth: Height: Weight: Physician you are seeing today: Marital Status: Married Work