Please Check the appropriate box: Single Divorced Married Widowed Number of Children & Ages:

Transcription

1 Date: Patient Information Last Name: First Name: Middle Initial: Address: City: State: Zip Code: Primary Number: Secondary Number: Mobile Number: Home Work Date of Birth: Age: Gender: M F Race (check one): White Black/African American Hispanic American Indian Asian Asian Indian Chinese Filipino Japanese Korean Vietnamese Native Hawaiian Samoan Guamanian or Chamorro Opt Out Other Multi Racial (check one) Yes No Unknown Please Check the appropriate box: Single Divorced Married Widowed Number of Children & Ages: Spouse's Name: Spouse's s Phone: Other Contact Person: Phone: Have you received chiropractic care in the past? Yes No If yes, please give the date and the name of the chiropractor, as well as the reason for the previous care: Name of your Medical Doctor: Name of your health insurance company: Insurance Policy Number: Complete if applicable to your current health condition: Personal Injury Auto Accident Workers Compensation If you have consulted an attorney, regarding the above, please provide your attorney's name and address: Name: Phone: Address: Page 1 of 5

2 Health Questionnaire Patient Condition Date: Reason(s) for visit: Is this condition due to an accident? Yes No Auto Work Home Other Date: When did your symptoms appear? Is you condition getting worse? Yes No How often do you have this problem? Is it constant or does it come and go? Does it interfere with your: Work Sleep Daily Routine Recreation Activities or movements that are difficult/painful to perform: Sitting Standing Walking Bending Lying Down Mark an "X" on the picture where you continue to have pain, numbness or tingling. Mark pain on the below scale 0 to 10: At Rest No Pain Extreme Pain With Activity No Pain Extreme Pain What treatments have you already received for your Condition? Medications Surgery None PhysicalTherapy Chiropractic Care Name of doctor(s) who have treated you for this condition Allergies Are you allergic to any medication(s)? Yes No If yes, which medications? Are you allergic to any of the following? Bee Sting Latex Peanuts Shellfish Dairy Mold Pollen Wheat Eggs Nuts Other Describe the Reaction: Smoking History Do you currently smoke tobacco of any kind? Yes Former smoker Never a smoker If yes, how often do you smoke? Current everyday smoker Current sometimes smoker If yes, what is your level of interest in quitting smoking? No interest Very interested Page 2 of 5

3 Medications Current medications, including frequency and dosage, if know. If not currently taking medications, check here: Medication Name Quantity/Dosage (ie 1 tablet/5mg.) Frequency (ie 2 times/day) Start Date If you currently take more than 6 medications, check here: Do you currently use any recreational drugs? Yes No Social History WORK ACTIVITY: What is your job description: What do you do most of the day at work? Sitting Standing Light Labor Heavy Labor Other: What job did you do during most of your life? How would you describe the physical stress level at work? Low Medium High EDUCATION: Mark highest level of education completed: Elementary School Middle School High School Vocational GED Associates Degree Bachelors hl Degree Graduate Degree Doctorate Other DIET/NUTRITION: Are you on any special diet? Yes No If yes, what reason: Is your weight a concern for you emotionally or physically? Yes No Have you gained or lost over 10 pounds in the past 6 months without wanting to? Yes No My dietary intake consists mainly of the following: (Mark all that apply) Fruits Vegetables Whole Grains High Fiber Low Fiber High Salt Low Salt High Sugar Low Sugar Low Carb High Fat Low Saturated Fat High Protein Low Calorie Rate your appetite on the scale below: Normal appetite Eat nothing How many 8 ounce glasses of water do you drink in a day? Alcohol Use: Now? Yes No Amount/Weekly: How Long? Past? Yes No Amount/Weekly: How Long? How many coffee caffeine drinks do you drink a day? Cups: How many soda caffeine drinks do you drink a day? Cans: Current Vitamins, minerals, Herbs, etc. List ANY/ALL non prescription items you are CURRENTLY taking. Vitamin, Mineral, Herbs Quantity/Dosage (ie 1 Frequency (ie 2 Start Date tablet/5mg.) times/day) Page 3 of 5

4 Social History (cont.) HEALTH REVIEW: How many hours of sleep are you getting per night? How would you rate your sleep on the following scale? Wake up Fully Rested No/Poor Sleep How many days a week do you exercise for 30 minutes or more? How would you rate the intensity of your exercise? High Intensity No Exercise What are your health goals? Personal Health History Are you currently under the care of a Healthcare Provider or any other doctor? Yes No If yes, for what condition(s)? Provider's Name: Phone: Has any doctor diagnosed you with Hypertension recently? Yes No If yes, describe: Has any doctor diagnosed you with Diabetes recently? Yes No If yes, was your blood lab work test for hemoglobin A1c >9.0%? Yes No Unsure If yes, other comments regarding Diabetes: Have you had an X ray, CT scan or MRI of your low back spine in the past 28 days? Yes No Have you seen a chiropractor in the past? Yes No Date of last visit: If yes,,previous Chiropractor information: Name: Location: Phone: Were you satisfied with your care? Yes No Why? Reason for leaving: Please check the box if you have had or currently suffer from the following: ADD Allergies/hay fever Alzheimer's Anemia Anxiety Arm/wrist pains Arthritis Asthma Bedwetting Cancer Cerebral palsy Chicken pox CVA (Stroke) Depression Diabetes Diarrhea / constipation Dizziness Ear infections Emphysema Fatigue Fibromyalgia Foot/ankle/knee High Blood Head aches Heart disease pains Pressure HIV IBS Neck/back pains Numbness in arms/ hands Psoriasis Scoliosis Seizures Shoulder pains Sleeping Stomach problems problems Thyroid problems Tingling in arms / legs Weight gain/loss Other information or health complaints you would like us to be aware of: Are you pregnant? Yes No Due Date: Any of the following? (include number) Pregnancies: Live Births: Miscarriages: Page 4 of 5

5 Personal Health History (cont.) Injuries/Surgeries you have had: Description Date Falls Head Injuries Broken Bones Dislocations Surgeries Have you ever: Description Date Lost Consciousness Used a Can/Crutch Had Mental/Emotional Disorders Been treated for Spine/Nerve Disorder Relation Mother Father Sister(s) Brother(s) Daughter(s) Son(s) Living Family History Deceased Age (now/at death) Serious Illness/Cause of death Purpose of this appointment: How long have you suffered with this problem? When and how did it start: What is the pattern of this problem? Constant Intermittent Occasional Cyclic What activities make this problem worse? What have you tried to get rid of the problem that didn't work? What gives you some temporary relief? On the scale below, rate your commitment in helping solve the problem Lowest Highest Patient's Signature Date Signature of Parent or Legal Guardian Relationship Referred to Verona Chiropractic, LLC by Page 5 of 5