ACTIVE EDGE CHIROPRACTIC

Transcription

1 ACTIVE EDGE CHIROPRACTIC HEALTH HISTORY QUESTIONNAIRE PERSONAL INFORMATION Name: Female Male Alberta Health Care# Address: City: Province: Postal Code: Telephone: Home: Work: Cell: Occupation: Birth Who Referred You To Our Clinic? Day Month Year Using symbols below, mark on body diagram: X = Pain O = Numbness Z = Tingling / = Other Using the line scale, indicate the severity of the pain you are experiencing now by circling a number: NO PAIN EXTREME PAIN Reason for appointment: When did this begin? Have you ever had similar problems? Yes No How did this occur? Is this condition related to: Work? Yes No Has your employer been notified? Yes No Motor Vehicle Accident? Yes No Date of Injury: Has the condition improved worsened unchanged since it began? What have you done for this condition? Have you had X-rays, MRI or other tests for this condition? What tests and when?

2 Can you perform your daily home activities? Yes Yes, only with help Not at all Can you perform your daily work activities? All activities Only some Not at all Describe your stress level: None Mild Moderate High Do you exercise? Daily Occasionally Not at all Please list any previous surgeries, illnesses, injuries (motor vehicle accident): Have you had any fractures or dislocations? Yes No Body part Have you had previous chiropractic care? Yes No Doctor: Family doctor name: List all medications: (prescriptions, vitamins, herbal supports, birth control, aspirin, Advil, Tylenol, Robax, etc.) What do you hope to achieve from this visit? Check all that apply. Pain relief Explanation of your condition Exercises to prevent recurrence Are you seeking: Lasting corrective care Temporary relief Circle the word that best describes the way you feel about your general health: excellent good acceptable uneasy concerned very concerned frustrated pained frightened distressed unbearable Have you recently experienced a major upset in your life? Yes No Explain: Have you or a family member ever been diagnosed or told you have any of the following? Please check the appropriate box. High Blood Pressure Yes No Family Hardening of the arteries Yes No Family Diabetes Yes No Family Tuberculosis Yes No Family Cancer, where? Yes No Family Heart or blood disease Yes No Family Stroke Yes No Family Osteoporosis Yes No Family Bone spurs on neck bones Yes No Whiplash injury (flexion-extension injury, cervical sprain) Yes No Were you ever a smoker? Yes No From to Visual disturbances (blurring, loss, double) Yes No Hearing disturbances (loss, ringing, other noise) Yes No Slurred speech or other speech problems Yes No Difficulty swallowing Yes No Dizziness Yes No Loss of consciousness, even momentary blackouts Yes No Numbness, loss of sensation, strength or weakness in the face, fingers, hands, arms, legs, or any other parts of the body Yes No Sudden collapse without loss of consciousness Yes No

3 SYSTEMS REVIEW Please circle any conditions that are presently causing you a problem and underline those that have caused you problems in the past. GENERAL SYMPTOMS Fever Sweats Fainting Sleep disturbance Fatigue Nervousness Weight loss Weight gain NEUROLOGICAL Visual disturbances Dizziness Fainting Convulsions Headache Numbness Neuralgia (nerve pain) Poor coordination Weakness EENT Eye pain Double vision Ringing in ears Deafness Nosebleeds Trouble swallowing Hoarseness Sinus infection Nasal drainage Enlarged glands RESPIRATORY Chronic cough Spitting up phlegm Spitting up blood Chest pain Wheezing Difficulty breathing Asthma CARDIOVASCULAR Rapid beating heart Slow beating heart High blood pressure Low blood pressure Pain over heart Hardening of arteries Swollen ankles Poor circulation Palpitations Cold hands or feet Varicose veins MUSCLE & JOINT Neck pain Low back pain Arm pain Shoulder pain Leg pain Knee pain Foot pain Pain/numbness down arms or legs Pain between shoulders Swollen joints Spinal curvature Arthritis Fractures GENITOURINARY Frequent urination Painful urination Blood in urine Pus in urine Kidney infection Prostate trouble Uncontrollable urine flow GASTROINTESTINAL Poor appetite Difficult digestion Heartburn Ulcers Nausea Vomiting Constipation Diarrhea Blood in stool Gallbladder/jaundice Colitis FOR WOMEN ONLY Painful menstruation Hot flashes Irregular cycle Cramps or back pain Vaginal discharge Nipple discharge Lumps in breast Menopausal symptoms Birth control pills Miscarriages Complications with pregnancy Pregnant? Y / N Week? Other: WRITTEN CONSENT TO NOTIFY FAMILY PHYSICIAN OF CHIROPRACTIC CARE At Active Edge Chiropractic, we strive to maintain open communication and professional relationships with other health care providers. In order to provide updates to your family doctor regarding your care, we need to obtain written consent from you as our patient. Please fill in the information below so we can inform your doctor about your diagnosis, treatment, and progress at our clinic. Dated this day of, 20. Family Physician s Name: Phone: Patient Signature: Witness Signature: Patient Name: Witness Name: CANADIAN CHIROPRACTIC PROTECTIVE ASSOCIATION

4 CANADIAN CHIROPRACTIC PROTECTIVE ASSOCIATION Informed Consent to Chiropractic Treatment FORM L There are risks and possible risks associated with manual therapy techniques used by doctors of chiropractic. In particular you should note: a) While rare, some patients may experience short term aggravation of symptoms or muscle and ligament strains or sprains as a result of manual therapy techniques. Although uncommon, rib fractures have also been known to occur following certain manual therapy procedures; b) There are reported cases of stroke associated with visits to medical doctors and chiropractors. Research and scientific evidence does not establish a cause and effect relationship between chiropractic treatment and the occurrence of stroke. Recent studies suggest that patients may be consulting medical doctors and chiropractors when they are in the early stages of a stroke. In essence, there is a stroke already in progress. However, you are being informed of this reported association because a stroke may cause serious neurological impairment or even death. The possibility of such injuries occurring in association with upper cervical adjustment is extremely remote; c) There are rare reported cases of disc injuries identified following cervical and lumbar spinal adjustment, although no scientific evidence has demonstrated such injuries are caused, or may be caused, by spinal adjustments or other chiropractic treatment; d) There are infrequent reported cases of burns or skin irritation in association with the use of some types of electrical therapy offered by some doctors of chiropractic. I acknowledge I have read this consent and I have discussed, or have been offered the opportunity to discuss, with my chiropractor the nature and purpose of chiropractic treatment in general, (including spinal adjustment), the treatment options and recommendations for my condition, and the contents of this Consent. I consent to the chiropractic treatment recommended to me by my chiropractor including any recommended spinal adjustments. I intend this consent to apply to all my present and future chiropractic care. Dated this day of, 20. Patient Signature (Legal Guardian) Witness of Signature Name: Name: CCPA12.08 (ENGLISH)

5 CASE HISTORY CHIEF COMPLAINT: AGE: Onset Progression Quality/Quantity N/T/W Radiation Setting Timing Aggravating Alleviating Meds Trauma Bowl/bladder function changes, unexplained weight loss, fever, chills, night sweats, nausea, vomiting, dizziness, blurred/double vision, dysphagia, nocturnal pain Denies all DDX: