HEALTH HISTORY QUESTIONNAIRE
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1 1525 S. Alafaya Trail Unit 105 / Orlando, FL T: F: HEALTH HISTORY QUESTIONNAIRE Name: Date: Address: City: State: Zip: S.S. #: Cell Phone: Home Phone: Work Phone: Age: Date of Birth: Gender: Marital Status: F M Single Married Divorced: Widowed: Primary Care Physician: Business/Employer: Type of Work: Height: Weight: Desired Weight: Have you been to a chiropractor before? Yes No When was the last time you had x-rays of your spine? Never Problem Date of Onset Example: Neck Pain May 2014 Severity(Scale 0-10) Treatment Tried 5/10 Acupuncture/Advil Success Mild Improvement What diagnosis or explanation, if any, has been given to you for these concerns? When was the last time you felt well?
2 What seems to worsen your symptoms? What seems to make you feel better? MEDICATIONS List all medications you are currently on. Include all over the counter non-prescription drugs. Name Date Started Date Stopped Dosage/Frequency List all vitamins, minerals and any nutritional supplements that you are taking now. Name Date Started Date Stopped Dosage/Frequency PAST MEDICAL AND SURGICAL HISTORY If you have experienced a reoccurrence of an illness, please indicate when or how often under the comments. ILLNESS WHEN/ONSET COMMENTS Arthritis Asthma Cancer Diabetes Epilepsy, Convulsions, Seizures Heart Attack, Angina Heart Failure
3 High Blood Pressure Stroke Thyroid Disease INJURIES WHEN COMMENTS Back Injury Broken Bones Head Injury Neck Injury Car Accidents DIAGNOSTIC STUDIES WHEN COMMENTS Bone Density Test Bone Scan CAT/CT Scan (Please include Type) EMG/NCV MRI (please indicate region) X-rays (please indicate region) SUGERIES WHEN COMMENTS Neck or Back FAMILY HISTORY WHO COMMENTS Heart Disease
4 Cancer Diabetes Autoimmune Disease Mental Illness HOSPITALIZATIONS WHERE HOSPITALIZED WHEN REASON REVIEW OF SYMPTOMS Check ( ) those items that applied to you in the past. Circle those that presently apply. GENERAL: Fever Aches/Pains General Weakness Swollen Glands Fatigue Difficulty falling asleep Daytime sleepiness SKIN: Rashes Dryness/cracking skin Bruise easily Changing Moles Skin cancer Shingles Acne Eczema Psoriasis HEAD: Poor Concentration Confusion Headaches: Severe Migraine Occipital Frontal Forgetfulness Poor memory EYES: Eye pains Double vision Blurred vision Cataracts Floaters in eyes Visual hallucinations Halo around lights
5 NOSE/SINUSES: Infection No sense of smell Polyps MOUTH: TMJ Issues Fever blisters THROAT: Difficulty swallowing Frequent hoarseness Enlarged glands GASTROINTESTINAL: Indigestion Heartburn Nausea Constipation Diarrhea Vomiting Changes in bowels Acid Reflux Abdominal Pains/Cramps Rectal Bleeding Bloody stools Gallstones Ulcers KIDNEY/URINARY TRACT: Frequent urination Night time urination Problem passing urine Painful/Burning urination Kidney stones/infections Blood in urine MEN S HISTORY (for men only): Have you had a PSA done? Yes No Prostate enlargement Genital Pain Hernia EARS: Aches Ringing Deafness/Hearing loss Frequent infections Tubes in ears Hearing aid Sensitive to loud noises NECK: Stiffness Swelling Lumps CIRCULATION/RESPIRATION: High Blood Pressure Chest pain Shortness of breath Irregular Heart Beat High Cholesterol High Triglycerides Dizziness upon standing Palpitations Night sweats Murmurs Heart Enlargement Emphysema Prior Heart Attack? / / JOINTS/MUSCLES/TENDONS: Pain wakes you Weakness in legs and arms Balance problems Muscle cramping WOMEN S HISTORY (for women only): Painful periods Endometriosis Non-period bleeding Vaginal Discharge Partial/Total Hysterectomy Breast Cancer Ovarian Cysts
6 MEN S HISTORY (cont): Prostate cancer Nocturia (urination at night) How many times at night? Urgency/Hesitancy/Change in Urinary Stream Loss of bladder control WOMEN S HISTORY (cont): Pregnant Infertility Heavy Bleeding Fibroid tumors/uterus Lumps in breasts NUTRITIONAL HISTORY How much of the following do you consume each week? Cups of Coffee: Soda: Alcohol: Do you currently follow a special diet or nutritional program? Yes No Diabetic Vegetarian Dairy Restricted Vegan Other (describe): LIFESTYLE HISTORY TOBACCO HISTORY Have you ever used tobacco? Yes No If yes, what type? Cigarettes Smokeless Cigar Pipe Patch/Gum How much? Number of years? If not a current user, year quit? Attempts to quit: ALCOHOL INTAKE How often do you consume alcohol? No longer drink alcohol 1-3 drinks per week 4-6 drinks per week 7-10 drinks per week >10 drinks per week Do you notice a tolerance to alcohol (can you hold more than others?) Yes No
7 SLEEP AND REST HISTORY Average number of hours that you sleep at night? Do you: Have trouble falling asleep? Use a sleeping aid? Feel rested upon waking? Snore? Have problems with insomnia? EXERCISE HISTORY Do you exercise regularly? Yes No If yes, please indicate: Type of Exercise Jogging/Walking Aerobics Strength Training Pilates/Yoga/Tai Chi Sports (tennis, golf, soccer, basketball) Other (please indicate) 1x 2x 3x 4x+ < >45
HEALTH HISTORY QUESTIONNAIRE
1525 S. Alafaya Trail Unit 105 / Orlando, FL 32828 T: 407-282-4449 F: 407-282-4438 www.synhealthcare.com HEALTH HISTORY QUESTIONNAIRE Name: Date: Address: City: State: Zip: S.S. #: Cell Phone: Home Phone:
CASE HISTORY. Address: City: State: Zip: Date of Birth: Age: address: Occupation: Employer: Spouse's Employer: Referred by:
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GASTROINTESTINAL & MINIMALLY INVASIVE SURGERY HEALTH HISTORY QUESTIONNAIRE Date Patient Name _ Date of Birth Age Daytime phone ( ) Other phone ( ) Email How did you hear about us? My doctor Yellow pages
Dr. Michelle Cruickshank
CHIROPRACTIC INTAKE FORM A Multidisciplinary approach to medicine is holistic and seeks to understand all factors that may be affecting your health. Please answer the following questions to the best of
Gender: M F Race: Caucasian African American Hispanic Other
Weight Loss Surgery Patient Information First Name: Middle Initial: Last: Date of Birth: Age: Social Security #: Gender: M F Race: Caucasian African American Hispanic Other Address: City: State: Zip: Home
John Wayne Cancer Institute Dr. Foshag Dr. Faries Dr. Bilchik Dr. Leuchter
John Wayne Cancer Institute Dr. Foshag Essner Dr. Fischer Dr. Faries Dr. Foshag Dr. Bilchik Dr. O'Day Dr. Leuchter Medical Questionnaire Reset Form Date: Name: Gender: Male Female Age: Last First Middle
Northeast Ohio Urogynecology Patient History Intake Form. Last Name First Name Age. Date of Birth Race Referring Physician.
Northeast Ohio Urogynecology Patient History Intake Form Last Name _First Name Age_ Date of Birth Race Referring Physician Reason for Visit: _ Allergies: Preferred Lab (circle): QUEST LABCARE PLUS LABCORP
GIDEON G. LEWIS, M.D.
GIDEON G. LEWIS, M.D. Date: LAST Name: FIRST Name: MIDDLE Initial: Address: City: State: Zip Code: Date of birth: / / Social Security #: - - Sex: M F Marital Status (Circle): Single Married Divorced Widowed
The Rehabilitation Institute Cancer Rehabilitation
DO NOT DRILL The Rehabilitation Institute Cancer Rehabilitation STAR Patient Intake Form Your Name: Date: Your date of birth: Age: Who referred you (if a healthcare provider, please provide address)? Doctors
Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?
PH NEW PATIENT HISTORY Patient Name Date of Birth MALE / FEMALE Date Occupation: Left handed or Right handed Marital Status: Single Married Divorced Widowed Children? Y or N # Previous Treating Physician: