Puritz Chiropractic Center Patient Health Questionnaire
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- Rebecca Martin
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1 PERSONAL INFORMATION Puritz Chiropractic Center Today's Date: File #: First Name: Middle Initial: Last Name: Preferred First Name / Nickname: Social Security #: - - Are you: right handed left handed ambidextrous Date of Birth: / / Age: Address: City: State: Zip: Phone: ( ) - Work: ( ) - ext. Cell: ( ) - Occupation: Employer: Business Address: Marital Status: S M D W Sex: M F Name of Spouse: Ages & Names of Children: Who Referred You To Our Office Or How Did You Hear About Us? Have You Had Previous Chiropractic Care? No Yes; if so please indicate when and the doctors name: Date of Your Last Physical Examination: / / CURRENT COMPLAINTS Pain Drawing: Please mark where and what type of pain you are currently experiencing. Use the symbols indicated to describe the type of pain or sensations you are feeling: Use these symbols to describe the type of pain or sensations you are feeling: >>> Aching pain /// Stabbing or Sharp pain XXX Burning pain === Numbness ooo Pins and Needles Page 1 of 5
2 Please list your complaints below with the most significant or primary complaint first: 1. Area of Pain: Frequency: intermittent occasional frequent constant 2. Area of Pain: Frequency: intermittent occasional frequent constant 3. Area of Pain: Frequency: intermittent occasional frequent constant 4. Other: In general my symptoms are worse in: AM Midday PM; my symptoms do not change with the time of day. Are your symptoms / condition: improving unchanged getting worse HISTORY Symptoms developed from: work injury car accident sports injury lifting/fall gradual unknown The pain began on or about:. The pain is chronic and originally began on or about: Describe how the symptoms began or what you think caused the symptoms / condition: List other doctors you have seen for this complaint, the type of treatment given, and the result of that treatment: Describe any past history of the same or similar complaint: MEDICAL HISTORY Page 2 of 5
3 CHECK HERE IF YOU HAVE HAD OR ARE EXPERIENCING ANY OF THE FOLLOWING SYMPTOMS: Blurring vision Buzzing or ringing in ears Headaches: Area of head: Dizziness Numbness How often: daily times per day Loss of bowel or Confusion times per week times per month bladder function Loss of sleep Constipation Stomach difficulty Chest pains Diarrhea Frequent urination Painful urination Rectal bleeding Frequent colds Difficulty swallowing Allergies Asthma Cancer:(Type) Do you have a pacemaker? Yes No Please list any serious illness or medical conditions you have had and associated treatment: Please list the name and address of your primary care physician & any specialist you have seen: SURGICAL HISTORY Please list any surgeries you have had; include date, type of surgery or for what condition and outcome: FAMILY HISTORY Please list any family history of heart disease, cancer, diabetes or other serious illness: _ Women Only Important - if you suspect you are currently pregnant, please notify the doctor immediately. X-rays should not be taken if you are pregnant! Are you pregnant? Yes No Date of last menstrual cycle: Do you have PMS? Yes No Page 3 of 5
4 WORK HISTORY Puritz Chiropractic Center How many hours do you normally work in a week? Are you currently not working? Yes No In a typical workday, I (circle the number of hours per day per activity) Sit hours Stand: hours Walk hours On the job, I perform the following activities: In terms of an 8-hour workday, "occasionally" = 33%, "frequently" = 34% to 66%, and "continuously" = 67% to 100% of the day. Not At All Occasionally Frequently Continuously Bend / Stoop Squat Crawl Climb Reach above shoulder level Crouch Kneel Balancing Pushing / Pulling _ Check the category that best describes your work: Sedentary: Lifting up to 10 lbs. maximum and occasionally lifting and / or carrying such articles as dockets, ledgers, and small tools. Although a sedentary job is defined as one which involves sitting, a certain amount of walking and standing is often necessary in carrying out job duties. Jobs are sedentary if walking is required only occasionally and other sedentary criteria are met. Light Work: Lifting 20 lbs. maximum with frequent lifting and / or carrying of objects weighing up to 10 lbs. Even though the weight lifting may be only a negligible amount, a job is in this category when it requires walking or standing to a significant degree or when it involves sitting most of the time with a degree of pushing and pulling or arm and / or leg controls. Medium Work: Lifting 50 lbs. maximum with frequent lifting and / or carrying of objects weighing up to 25 lbs. Heavy Work: Lifting 100 lbs. maximum with frequent lifting and / or carrying of objects weighing up to 50 lbs. Very Heavy Work: Lifting objects in excess of 100 lbs. with frequent lifting and / or carrying of objects weighing 50 lbs. or more. SOCIAL HISTORY Do you smoke? N o Yes; if yes, how many packs of cigarettes do you smoke per day? How many cups of coffee or caffeinated drinks do you have per day? Do you consume alcohol? No Yes; if yes, would you say that your use of alcohol is occasional frequent or daily. Would you say your consumption of alcohol is light, medium, or heavy? Do you have a regular program of exercise? No Yes, if yes, please note the frequency and type of exercise that you do: List any hobbies or recreational sports / activities you enjoy doing: Fill This Section Out If Your Injury Is Related To an Automobile Accident Page 4 of 5
5 Date of accident: Hour: AM PM Were you the driver passenger: front seat back seat; pedestrian. Were the roads dry wet snowy. Were you struck from behind driver's side passenger's side head on. Were you wearing a seat belt Yes No Do you recall any part of your head or body striking any part of the interior of the car? Yes No If yes, please describe: Type of vehicle you were in? Type of vehicle that struck you? Head / body position at time of impact: head turned to left / right head looking back head straight forward body straight in sitting position body rotated to left / right other: Did you feel pain immediately gradually next day other: Were you knocked unconscious? Yes No. Did you receive first aid? Yes No Did you go to the hospital by ambulance, a friend, or did you drive yourself. Name of hospital: Did the hospital take x-rays? Yes No. What treatment was given? Have you been unable to work because of the accident? No Yes; if yes since when: / / Have you consulted an attorney? No Yes; if yes please give name, address, and phone: Fill This Section Out If Your Injury Is Related To a Work Accident Date of accident: / / Hour: AM PM Did you report the accident to your supervisor within 48 hours? Yes No Did a fellow employee witness the accident? Yes No Have you been unable to work because of the accident? No Yes; if yes since when: / / Have you consulted an attorney? No Yes; if yes please give name, address, and phone: Patient s Signature: Date: / / (or guardian if child) Page 5 of 5
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eas 634 N. STATE STREET, WESTERVILLE OH, 43082 (614) 901-WELL www.abilitychiro.com Name: Age: Date: Address: City: State: Zip Code: Alternate Address: City: State: Zip Code: Cell Phone: ( ) Cell Phone
Patient History (Please Print)
Patient History (Please Print) Date: Name: Email: Phone: (Home) (Mobile) (Work) Address: City: Zip: Birth Date: / / Male Female Spouse/Parent Name: # of Children: Married Single Divorced Widowed Are you
ABUNDANT HEALTH CHIROPRACTIC New Patient Form PERSONAL INFORMATION. Name: Gender: M F Today's Date: / / Birth Date: / / Age: Social Security #: - -
ABUNDANT HEALTH CHIROPRACTIC New Patient Form PERSONAL INFORMATION Name: Gender: M F Today's Date: / / Birth Date: / / Age: Social Security : - - Home Address: City, State, Zip: Home Phone: ( ) Work Phone:
Patient Profile. Full Name: Address: Work Phone: Date of Birth: Social Security #: (Circle One) Full Time / Part Time. Emergency Contact: Number:
Patient Profile Full Name: Address: City: State: Zip Code: Home Phone: Cell Phone: Work Phone: Date of Birth: Social Security #: Email Address: Employer: (Circle One) Full Time / Part Time Emergency Contact:
HEALTH INFORMATION FORM
#102, 506-71 Ave SW Calgary AB T2V 4V4 Ph 587.352.9199 Fax 1.888.501.1724 info@fullcirclecalgary.ca www.fullcirclecalgary.ca Part 1: BASIC INFORMATION HEALTH INFORMATION FORM Name: Date: Address: City:
MOORE CHIROPRACTIC CENTER 707 Sunset Street Denton, TX (940)
MOORE CHIROPRACTIC CENTER 707 Sunset Street Denton, TX 76201 (940) 383-9399 Date Date of Accident File # ACCIDENT HISTORY REPORT Name Address City State Zip Children Date of Birth / / Sex M F Marital Status
PATIENT INFORMATION SHEET
PATIENT INFORMATION SHEET Patient Name Phone # Address (Florida): City State Zip Code Address (Not Florida): City State Zip Code Phone # Social Security # Birth date Sex (circle one) Male Female Marital
Chiropractic Case History/Patient Information
1 Chiropractic Case History/Patient Information Name: Social Security # Home Phone: Address City: State: Zip: E-mail address: Fax # Cell Phone: Age: Birth Race: Marital: M S W D Occupation: Office Phone:
Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Address:
Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Email Address: Emergency Contact Name and Phone Number: Family Doctor Name and Address:
Saleeby Chiropractic Centre, P.A.
Saleeby Chiropractic Centre, P.A. Stephen M. Saleeby, D.C. Wayne J. Prickett, D.C. Today s Date: / / Chiropractic Intake Z: Name: DOB: / / Age: First MI Last Preferred Name: Address City State Zip Code