Patient Intake Form. Name: Date of Birth: Social Security No.: Address: City: State: Zip:

Transcription

1 Patient Intake Form Name: Date of Birth: Social Security No.: Address: City: State: Zip: Phone (circle 1) home / cell / work: Marital Status: Single / Married / Divorced / Widowed Work Status: Employed / Full time student / Part time student / Other Race (circle only 1) White Black or African American Asian American Indian Alaska Native Native Hawaiian Other Pacific Islander Declined to State Preferred Language Ethnicity (circle only 1) Hispanic or Latino Not Hispanic or Latino Declined to State How did you learn of this clinic? Are your present problems due to an injury? Yes No Enter the date of the injury: Was the injury? Job Related Auto Accident Personal Injury Other: Has the accident been reported? Yes No If so, to whom? To Employer Auto Carrier Other: Briefly describe the accident, injury or illness: List symptoms experienced immediately after onset: Choose the severity level associated with each symptom List symptoms you are experiencing today: Choose the severity level associated with each symptom

2 List any tests, studies or medications received for this condition: Tests/Studies: Medications: Where you admitted to the hospital due to this condition: Yes No If yes, what hospital? Transported by? Ambulance Police Other: Date Admitted: Date Released: Length of Stay: List the hospital procedures received: Do you have any current work restrictions due to this condition? Off work: Yes No Previously From: To: Light duty: Yes No Previously (If yes, what are/were your restrictions?) What type of work do you do? Do you suffer from any condition other than that for which you are now consulting us? Yes No HABITS Current Every Day Smoker Former Smoker Current Some Day Smoker Never Smoker Drinking Alcohol: (Cups/day): Coffee Cups/Day: Soft Drink Bottles or Cans/Day: Water Cups/Day: EXERCISE FAMILY HISTORY None Diabetes Cancer Back Pain Other Moderate Mother Daily Father Sibling(s)

3 Are you taking any medication (prescription or over-the-counter)? Yes No If Yes, please indicate the following: Medication: Medication: Route: Oral / Topical / Injection Route: Oral / Topical / Injection Other: Frequency: Began Use: Other: Frequency: Began Use: Medication: Medication: Route: Oral / Topical / Injection Route: Oral / Topical / Injection Other: Frequency: Began Use: Other: Frequency: Began Use: Have you taken any medications in the past? Yes No If yes, which ones?: Do you have allergies to medication? Yes No If Yes, please indicate the following: Allergy: Allergy: Reaction: Reaction: Allergy: Allergy: Reaction: Reaction: Have you ever had any surgeries? Yes No (If yes, please list and enter the approximate date of surgery). Have you ever had X-rays taken? Yes No When? By Whom? For what ailments were these X-rays taken?

4 Azle Chiropractic Clinic PC Review of Systems Patient Name: Today's Date: Please check the signs and/or symptoms related to the following body systems you now have or have experienced in the past. CONSTITUTIONAL EYES CARDIOVASCULAR RESPIRATORY Chills Blindness Angina Asthma Drowsiness Blurred Vision Chest Pain Bronchitis Fainting Cataracts Claudication Dry Cough Fatigue Change in Vision Heart Murmur Productive Cough Fever Double Vision Heart Problems Coughing up Blood Night Sweats Dry Eyes High Blood Pressure Difficulty Breathing Weakness Eye Pain Low Blood Pressure Difficulty Sleeping Weight Gain Field Cuts Orthopnea Hemoptysis Weight Loss Glaucoma Palpitations Pneumonia Sensitivity to Light Shortness of Breath Sputum Production Tearing Swelling of Legs Wheezing Wears Glasses Varicose Veins INTEGUMENTARY GASTROINTESTINAL GENITOURINARY Breast Lumps / Pain Abdominal Pain Birth Control Therapy Change in Nail Texture Belching Burning Urination Change in Skin Color Black, Tarry Stools Cramps Eczema Constipation Erectile Dysfunction Hair Growth Diarrhea Frequent Urination Hair Loss Heartburn Hesitancy / Dribbling History of Skin Disorders Hemorrhoids Hormone Therapy Hives Indigestion Irregular Menstruation Itching Jaundice Lack of Bladder Control Paresthesia Nausea Prostate Problems Rash Rectal Bleeding Urine Retention Skin Lesions Abnormal Stool Caliber Vaginal Bleeding Abnormal Stool Color Vaginal Discharge Abnormal Stool Consistency Vomiting Vomiting Blood ENDOCRINE Cold Intolerance NEUROLOGICAL PSYCHIATRIC Diabetes Excessive Appetite Change in Concentration Agitation Excessive Hunger Change in Memory Anxiety Excessive Thirst Dizziness Appetite Changes Goiter Headache Behavioral Changes Hair Loss Imbalance Bipolar Disorder Heat Intolerance Loss of Consciousness Confusion Unusual Hair Growth Loss of Memory Convulsions Voice Changes Numbness Depression Seizures Homicidal Indication HEMATOLOGIC / LYMPHATIC Sleep Disturbance Insomnia Slurred Speech Location Disorientation Anemia Stress Memory Loss Bleeding Strokes Substance Abuse Blood Clotting Tremors Suicidal Indication Blood Transfusions Time Disorientation Bruise Easily Lymph Node Swelling MUSCULOSKELETAL Arthritis Neck Pain Decreased Motion Gout Injuries Joint Pain Joint Stiffness Locking Joints Back Pain Muscle Cramps Muscle Pain Muscle Twitching Muscle Weakness Swelling ENMT Bad Breath Dentures Deviated Septum Difficulty Swallowing Discharge Dry Mouth Ear Drainage Ear Pain Frequent Sore Throats Head Injury Hearing Loss Hoarseness Loss of Smell Loss of Taste Nasal Congestion Nose Bleeds Post Nasal Drip Sinus Infections Runny Nose Snoring Sore Throat Ringing in Ears TMJ Problems Ulcers ALLERGIC / IMMUNOLOGIC History of Anaphylaxis Itchy Eyes Sneezing Specific Food Intolerance

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