Today s Date: PATIENT DEMOGRAPHICS
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1 Whom may we thank for referring you to this office Today s Date: PATIENT DEMOGRAPHICS? APPLICATION FOR CARE HRN: Name: Birth Date: - - Age: Male Female Address: City: State: Zip: Address: Home Phone: Mobile Phone: Marital Status: Single Married Do you have Insurance: Yes No Work Phone: Social Security #: Driver s License #: Employer: Occupation: Spouse s Name Spouse s Employer Number of children and Ages: Name & Number of Emergency Contact: Relationship: HISTORY of COMPLAINT Please identify the condition(s) that brought you to this office: Primarily: Secondarily: Third: Fourth: On a scale of 1 to 10 with 10 being the worst pain and zero being no pain, rate your above complaints by circling the number: Primary or chief complaint is : Second complaints is : Third complaint: : Fourth complaint: : When did the problem(s) begin? When is the problem at its worst? AM PM mid-day late PM How long does it last? It is constant OR I experience it on and off during the day OR It comes and goes throughout the week How did the injury happen? Condition(s) ever been treated by anyone in the past? No Yes If yes, when: by whom? How long were you under care: Name of Previous Chiropractor: What were the results? N/A *PLEASE MARK the areas on the Diagram with the following letters to describe your symptoms: R = Radiating B = Burning D = Dull A = Aching N = Numbness S = Sharp/ Stabbing T= Tingling What relieves your symptoms? What makes them feel worse? Please List Any Medications You Are Taking: Reason You Are Taking It/Why It Was Prescribed
2 Is your problem the result of ANY type of accident? Yes, No Identify any other injury(s) to your spine, minor or major, that the doctor should know about: PAST HISTORY Have you suffered with any of this or a similar problem in the past? No Yes If yes how many times? When was the last episode? How did the injury happen? Other forms of treatment tried: No Yes If yes, please state what type of treatment:, and who provided it: How long ago? What were the results. Favorable Unfavorable please explain. Please identify any and all types of jobs you have had in the past that have imposed any physical stress on you or your body: If you have ever been diagnosed with any of the following conditions, please indicate with a P for in the Past, C for Currently have and N for Never have had: Broken Bone Dislocations Tumors Rheumatoid Arthritis Fracture Disability Cancer Heart Attack Osteo Arthritis Diabetes Cerebral Vascular Other serious conditions: PLEASE identify ALL PAST and any CURRENT conditions you feel may be contributing to your present problem: HOW LONG AGO TYPE OF CARE RECEIVED BY WHOM INJURIES SURGERIES CHILDHOOD DISEASES ADULT DISEASES SOCIAL HISTORY 1. Smoking: cigars pipe cigarettes How often? Daily Weekends Occasionally Never 2. Alcoholic Beverage: consumption occurs Daily Weekends Occasionally Never 3. Recreational Drug use: Daily Weekends Occasionally Never 4. Hobbies -Recreational Activities- Exercise Regime: How does your present problem affect the following FAMILY HISTORY: 1. Does anyone in your family suffer with the same condition(s)? No Yes If yes whom: grandmother grandfather mother father sister s brother s son(s) daughter(s) Have they ever been treated for their condition? No Yes I don t know 2. Any other hereditary conditions the doctor should be aware of. No Yes: I hereby authorize payment to be made directly to Performance Chiropractic & Sports Medicine, for all benefits which may be payable under a healthcare plan or from any other collateral sources. I authorize utilization of this application or copies thereof for the purpose of processing claims and effecting payments, and further acknowledge that this assignment of benefits does not in any way relieve me of payment liability and that I will remain financially responsible Performance Chiropractic & Sports Medicine for any and all services I receive at this office. Patient or Authorized Person s Signature Doctor s Signature - - Date Completed - - Date Form Reviewed
3 Patient s Name: HR#: / / JDD,DC 5/2011 Activities of Daily Living/Symptoms/Medications Patient Name: Date: File# Daily Activities: Effects of Current Conditions On Performance Please identify how your current condition is affecting your ability to carry out activities that are routinely part of your life: Bending No Effect Painful (can do) Painful (Limits) Unable to Perform Concentrating No Effect Painful (can do) Painful (Limits) Unable to Perform Doing computer Work No Effect Painful (can do) Painful (Limits) Unable to Perform Gardening No Effect Painful (can do) Painful (Limits) Unable to Perform Playing Sports No Effect Painful (can do) Painful (Limits) Unable to Perform Recreation Activities No Effect Painful (can do) Painful (Limits) Unable to Perform Shoveling No Effect Painful (can do) Painful (Limits) Unable to Perform Sleeping No Effect Painful (can do) Painful (Limits) Unable to Perform Watching TV No Effect Painful (can do) Painful (Limits) Unable to Perform Carrying No Effect Painful (can do) Painful (Limits) Unable to Perform Dancing No Effect Painful (can do) Painful (Limits) Unable to Perform Dressing No Effect Painful (can do) Painful (Limits) Unable to Perform Lifting No Effect Painful (can do) Painful (Limits) Unable to Perform Pushing No Effect Painful (can do) Painful (Limits) Unable to Perform Rolling Over No Effect Painful (can do) Painful (Limits) Unable to Perform Sitting No Effect Painful (can do) Painful (Limits) Unable to Perform Standing No Effect Painful (can do) Painful (Limits) Unable to Perform Working No Effect Painful (can do) Painful (Limits) Unable to Perform Climbing No Effect Painful (can do) Painful (Limits) Unable to Perform Doing Chores No Effect Painful (can do) Painful (Limits) Unable to Perform Driving No Effect Painful (can do) Painful (Limits) Unable to Perform Performing Sexual Activity No Effect Painful (can do) Painful (Limits) Unable to Perform Reading No Effect Painful (can do) Painful (Limits) Unable to Perform Running No Effect Painful (can do) Painful (Limits) Unable to Perform Sitting to Standing No Effect Painful (can do) Painful (Limits) Unable to Perform Walking No Effect Painful (can do) Painful (Limits) Unable to Perform
4 Review of Systems GENERAL APPEARANCE Weight Loss Weight Gain Change in Sleeping Patterns Change in Activity Capacity NEUROLOGICAL Anxiety Headaches Depression Meningitis Paralysis Seizure Stroke Tingling Tremors Memory Loss Fainting spells Dizziness Head injuries Blackouts or near blackouts Change in sensation anywhere on your body Localized weakness or numbness EARS, EYES, NOSE, & THROAT Hay fever Glaucoma Polyps Allergy Cataracts Goiter Hoarseness Double vision Gum problems Eye problems Ear Infections Glasses/contacts Hearing Loss Ear discharge/pain Frequent nosebleeds Ringing in your ears Sinus infections Swollen glands CARDIOVASCULAR Angina Leg cramps Ankle swelling Awakening at night short of breath & getting out of bed Cardiac catheterization Cold hands or feet Congenital heart defects Dizziness when standing up quickly Heart attacks Heart failure High or low blood pressure Irregular heart rate Purple fingers or lips Leg pain that resolves with rest Heart palpitations Varicose veins Chest pains Murmurs RESPIRATORY Asthma Breathlessness when lying flat Prolonged cough Coughing up blood Emphysema Pneumonia Frequent infections (bronchitis) Wheezing Pleurisy Shortness of breath Tuberculosis SKIN Abscess Dandruff Acne Oily skin Boils Rashes Hives Dry skin Lumps Psoriasis Jaundice Athlete's foot Excessive body odor Excessive sweating Fungal infections Nail problems Moles- irregular Moles - change/new KIDNEYS & URINARY TRACT Blood in urine Brown urine Dribbling after urination Painful urination Excessive thirst Involuntary urination/incontinence Urinating frequently (day) Urinating frequently (night) Urine hesitancy Weak flow Frequent bladder infections Kidney disease Kidney stone ENDOCINE Diabetes Sickle cell Abnormal body hair Changes in skin texture Cold intolerance Heat intolerance History of "borderline" diabetes MUSCULOSKELETAL Anemia Arthritis Back pain Bursitis Gout Joint aches Neck pain Tendinitis Abnormal Blood Counts Blood clots in legs/lungs Bone Marrow Biopsy Easy Bleeding Easy bruising Joint swelling Morning stiffness Muscle aches GASTROINTESTINAL Diarrhea Reflux Ulcers Hepatitis Abdominal pain Anal fissures Black tarry stools Vomiting blood Constipation Nausea Problems swallowing Hiatal Hernia Intestinal obstruction Liver disease Hemorrhoids Red blood after bowel movements Gallstones Vomiting Heartburn Indigestion MALE & FEMALE Painful sexual intercourse Loss of sexual interest Unprotected sex Groin itching Sexually transmitted diseases MALES ONLY Hernia Sterility Bloody ejaculation Inability to complete intercourse Lump on testicle Penile discharge Problems maintaining or keeping an erection Prostate disease Sores on penis or warts Testicular pain Testicular swelling FEMALES ONLY D & C Hot flashes Hernia Fibroids Abnormal bleeding between cycles Abnormal pap smear Bleeding after intercourse Complications w/ pregnancy PMS Endometriosis Heavy bleeding during cycles Discharge from breast Ovarian cysts Pelvic Inflammatory Disease Postmenopausal symptoms Vaginal discharge Vaginal Dryness Vaginal warts Not Listed Above:,DC 5/2011
5 Patient Name File#/HRN Date INITIAL NERVE SYSTEM PROFILE When was your most recent auto accident? What speed was the collision? Type of impact: Front Impact / Side Impact / Rear Impact Was treatment received? Please describe When was your most recent strain / stress at work? Please describe the manner of the injury Was treatment received? Please describe Does your job require you remain in long term stressful postures? (i.e. all day seating, repeated lifting, long term computer use) Spinal traumas in the past? Collision, quick burst, or repetitive motion sports: football, wrestling, basketball, baseball, soccer, tennis, golf, track and field Trauma as a child! i.e. fall on your head, impact to your head, concussion, fall onto your back or tailbone, biking accident Work around the house lifting, bending, woke up with stiff neck, back went out Doctor Signature Date, DC 5/2011
LIST RESTRICTED ACTIVITY: CURRENT ACTIVITY LEVEL USUAL ACTIVITY LEVEL
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Temp: BP: Ht: P: WT: R: NEW PATIENT HISTORY AND PHYSICAL FORM Patient s Name: Age: Sex: Male Female CHIEF COMPLAINT: (why you are here today) History of Present Illness LOCATION of pain / problem? HOW
Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Address:
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