INTRODUCTION PATIENT CASE HISTORY
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- Brenda Lyons
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1 INTODUCTION PATIENT CASE HISTOY Today s Date: / / PATIENT INFOMATION Name: (First MI ast) Preferred Name: Address: City: State: Zip: Date of Birth: Gender: Male Female Social Security #:_ Home: Mobile: Work: Preferred Method of Contact: Text Home Phone Other: *eferred By: (Name) Family Friend Co-Worker Doctor Other: ace & Ethnicity: (Choose up to 2) Preferred anguage: African American or Black English American Indian or Alaskan Native Spanish Asian Other: Hispanic or atino Decline Native Hawaii or Other Pacific Islander White Decline EMEGENCY CONTACT INFOMATION Name: (First MI ast) Home: Mobile: elationship: Child Parent Spouse Other: Primary Care Physician: Doctor s Phone: FINANCIA INFOMATION Is today s visit the result of an accident? No Auto Work Other: Will we be working with insurance? No Yes (Details) Primary: ID#: Secondary: ID#: Where would you like statements sent? Self Other (Details below) Name: Address: Phone: It is Usual and Customary to Pay for Services as endered Unless Otherwise Arranged Account No: Seamless, C Page 1 of 4
2 HISTOY OF PESENT INESS (Please describe) Major Complaint: When did it start? / / HISTOY OF PESENT INESS Secondary Complaints: What happened? Which daily activities are being affected by this condition? ocation of Symptoms and adiation P Pain T Tender N Numb H Hypoesthesia S Spasm Grade Intensity/Severity: (0/10) Mild (1-2/10) Mild-Moderate (2-4/10) Moderate (4-6/10) Moderate-Severe (6-8/10) Severe (8-10/10) Frequency: Off & On Constant MAJO COMPAINT Quality: Sharp Stabbing Burning Achy Dull Stiff & Sore Other: Does it radiate? No Yes (Please indicate on drawing) Improves with: Ice Heat Movement Stretching OTC Medications: Worsens with: Sitting Standing/Walking ying Down/Sleeping Overuse/ifting Previous Treatment: Chiropractor Medical Doctor Physical Therapy E/Urgent Care Orthopedic Previous Diagnostic Testing: X-rays MI CT *Women: Are you pregnant? No Yes ast Menstrual Period: / / Due date: / / Present Illness Comments: Prescription Medications & Supplements: Yes (ist Name, dosage, frequency) Allergies to Medications: No known drug allergies Yes (ist - Name and reaction) Today s Date: Patient Name: _ Account No: Seamless, C Page 2 of 4
3 PAST, FAMIY, AND SOCIA HISTOY PAST MEDICA HISTOY Have you ever had any of the following? (Please select all that apply and use comments to elaborate.) Illnesses: Asthma Autoimmune Disorder (Type) Blood Clots Cancer (Type) CVA/TIA (stroke) Diabetes Migraine Headaches Osteoporosis Injuries: Back Injury Broken Bones Head Injury Neck Injury Falls Hospitalizations: (Non-surgical with Date) Surgeries: (If yes, provide type & surgery date) Cancer Orthopedic Shoulder / Elbow/Forearm / Wrist/Hand / Hip / Knee / Ankle/Foot / Spinal Surgery Neck: Back: Medical History Comments: FAMIY HISTOY (Please mark X to all that apply and use comments to elaborate.) Unknown Age at death (if Deceased) Aneurysms CVA (Stroke) Cancer Diabetes Heart Disease Hypertension Other Family History Unremarkable Mother Father Gender F M Sibling1 Sibling2 Sibling3 Child1 Child2 Child3 Family History Comments: SOCIA AND OCCUPATIONA HISTOY Marital Status: Single Married Divorced Other Children: Other: Student Status: Full Student Part Student Non-Student Highest level of Education: High School College Grad. Post Grad. Other: Employed: No Yes (Occupation) Dominant Hand: ight eft Ambidextrous Smoking/Tobacco Use: If current smoker, amount = Every Day Some Days Former Never Alcohol Use: Every Day Weekly Occasionally Never Caffeine Use: Coffee Tea Energy Drinks Soda Never Exercise frequency: Daily 3-4xs/week 2-3xs/week arely Never Social History Comments: Today s Date: Patient Name: _ Account No: Seamless, C Page 3 of 4
4 EVIEW OF SYSTEMS EVIEW OF SYSTEMS Many of the following conditions respond to Chiropractic and Acupuncture treatment. Are you currently experiencing any of these symptoms? (Please select all that apply and use comments to elaborate.) Constitutional: (General) Fever Fatigue Musculoskeletal: Joint Pain/Stiffness/Swelling Muscle Pain/Stiffness/Spasms Broken Bones Neurological: Dizziness or ightheaded Convulsions or Seizures Tremors Psychiatric: (Mind/Stress) Nervousness/Anxiety Depression Sleep Problems Memory oss or Confusion Genitourinary: Frequent or Painful Urination Blood in Urine Incontinence or Bed Wetting Painful or Irregular Periods Gastrointestinal: oss of Appetite Blood in Stool or Black Stool Nausea or Vomiting Abdominal Pain Frequent Diarrhea Constipation Cardiovascular & Heart: Chest Pains/Tightness apid or Heartbeat Changes Swelling of Hands, Ankles, or Feet espiratory: Difficulty Breathing Cough Other: Eyes & Vision: Eye Pain Blurred or Double Vision Sensitivity to ight Head, Ears, Nose, & Mouth/Throat: Frequent or ecurrent Headaches Ear - Ache/inging/Drainage Hearing oss Sensitivity to oud Noises Sinus Problems Sore Throat Endocrine: Infertility ecent Weight Change Eating Disorder Hematologic & ymphatic: Excessive Thirst or Urination Cold Extremities Swollen Glands Integumentary: (Skin, Nails, & Breasts) ash or Itching Change in Skin, Hair, or Nails Non-healing Sores or esions Change of Appearance of a Mole Breast Pain, ump, or Discharge Allergic/Immunologic: Food Allergies Environmental Allergies eview of Systems Comments: I have answered these questions to the best of my knowledge and certify them to be true and correct. Patient or Guardian Signature Date Today s Date: Patient Name: _ Account No: Seamless, C Page 4 of 4
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INTRODUCTION PATIENT CASE HISTORY
INTODUCTION PATIENT CASE HISTOY Today s Date: / / PATIENT INFOMATION Name: (First MI ast) Preferred Name: Address: City: State: Zip: Date of Birth: Gender: Male Female Social Security #:_ Home: Mobile:
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History # UPIN # (Please leave blank) Name: First M.I. Last Address: Street (Apt #) City State Zip Code Phone number: ( ) ( ) Home Business Birth Date: / / Day-Month-Year Gender: M F Marital status: (Maiden
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Patient Information Last Name: First Name: Middle Initial: Address: City: State: Zip Code: Date of Birth (MM/DD/YY): Social Security #: Sex: Male Female Home Phone #: Mobile Phone #: Email Address: Marital
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WELCOME TO THE MILLER CHIROPRACTIC CLINIC We are pleased that you have chosen to consult us regarding your health. In order to help us evaluate your condition thoroughly, please complete the following
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Date Name / / last first middle initial Personal Health # - Male Female Home Address City Postal Code Home Telephone # Business Telephone # Cell # E-Mail Address Best way to contact you: Home # Work #
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