Employment Status: Employed FT Student PT Student Retired Self Employed Other
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1 COMPLETE HEALTH Date: / / PATIENT INFORMATION First Name: Home Phone: ( ) - Last Name: Work Phone: ( ) - Date of Birth / / Sex: M F Cell Phone: ( ) - Address: Apt. # Is it ok to call you at work?: Yes _ City: State: Zip: EMERGENCY CONTACT: Relationship: Phone: Employer: How did you hear about us? Address: Spouse is a patient Name: City: State: Zip: Referred by: Marital Status: Single Married Other Internet Insurance Co. Physician DEMOGRAPHICS Employment Status: Employed FT Student PT Student Retired Self Employed Other Race: White Black/African American Hispanic Asian Indian Asian American Indian/Alaskan Native Chinese Vietnamese Japanese Native Hawaiian/Pacific Island Korean Filipino Samoan Guamanian/Chamorro I choose not to specify Other: Multi-Racial: Yes Unknown Ethnicity: Hispanic or Latino t Hispanic or Latino I choose not to specify Preferred Language: English Spanish Chinese German American Sign Language French Tagalog Italian Japanese Polish French Creole Koren Arabic Russian Armenian Greek Portuguese Hindi Persian Gujarati Vietnamese Urdu I choose not to specify VERIFICATION QUESTION (For access to your electronic health records) What is the name of your favorite pet? In what city were you born? What high school did you attend? What was the make of your first car? What is your favorite movie? On what street did you grow up? What is your mother's maiden name? When is your anniversary? Answer to the chosen question: ACCIDENT INFORMATION Is your condition due to an accident? Yes Date of Accident: / / Type of Accident: Auto Work Home Other To whom have you made a report of your accident? Auto Insurance Employer Workers Comp. Other
2 SYMPTOM INFORMATION By using the key below, please indicate on the body diagram where you are experiencing the following symptoms: # = Numbness X = Burning / = Stabbing 0 = Pins & Needles + = Dull Ache Describe your symptoms: When did your symptoms start? / / How did your symptoms begin? 1. Frequency of symptoms: Constantly Frequently Occasionally Intermittently 2. Type of pain: Sharp Dull ache Numb Shooting Burning Tingling Stabbing 3. Changes in pain? Getting better t changing Getting worse 4. Over 4 weeks, indicate the average intensity of your symptoms: 0 None Unbearable 5. Over 4 weeks, has pain interfered with your normal work/housework? t at all A little bit Moderately Quite a bit Extremely 6. Over 4 weeks, has pain interfered with your social activities? All of the time Most of the time Some of the time A little of the time ne of the time 7. Your overall health right now is: Excellent Very good Good Fair Poor 8. Other doctors? ne Other Chiropractor Medical Doctor Physical Therapist Other 9. Other treatment types? Adjustments Physical Therapy Medication Surgery Other 10. When was this treatment? In the last month 2-3 months 3-6 months 6 months - 1year 1-2 years 2-5 years 5-10 years 11. Imaging: X-rays MRI CT Scan Other 12. When was the imaging? In the last month 2-3 months 3-6 months 6 months - 1year 13. Similar symptoms in the past? Yes 1-2 years 2-5 years 5-10 years 14. Previous treatment? This office Other Chiro. Medical Doctor Physical Therapist Other 15. Occupation: Professional/Executive White Collar/Secretarial Tradesperson Laborer Homemaker Student Retired Other 16. If you are not retired, a home maker, or a student, what is your work status? Full-time Part-time Self-employed Unemployed Off Work Other
3 CURRENT HEALTH Family Physician: Allergies: Latex Adhesive Telephone: ( ) - Other: Fax: ( ) - Are you Pregnant? Yes No Due Date: / / HEALTH HISTORY Please describe any injuries/surgeries you have had: Falls: Date: Head Injuries: Date: Broken Bones: Date: Dislocations: Date: Surgeries: Date: FAMILY HISTORY Has anyone in your family ever had any of the following? Please specify (parents and siblings only): Arthritis Yes Relation: Cancer Yes Relation: Cholesterol Problems Yes Relation: Diabetes Yes Relation: Heart Problems Yes Relation: High Blood Pressure Yes Relation: Stroke Yes Relation: Thyroid Problems Yes Relation: Do you have any children? Male under 6 years Male under 10 years Male under 19 years Male over 19 years Female under 6 years Female under 10 years Female under 19 years Female over 19 years SOCIAL HISTORY Caffeine Use: Never Occasionally Often Amphetamine Use: Past Present Drink Alcohol: Never Occasionally Often Barbiturate Use: Past Present Chew Tobacco: Never Occasionally Often Cocaine Use: Past Present Experience Stress: Never Occasionally Often Crystal Meth Use: Past Present Exercise: Never Occasionally Often Heroin Use: Past Present Wear Seat Belt: Never Usually Always Marijuana Use: Past Present Smoke: 1 pack or less a day 1 pack or more a day ACTIVITIES Occupational: Manual Labor: Light Medium Heavy Recreational:
4 REVIEW OF SYMPTOMS Have you had trouble with any of the following: Cardiovascular: Ears/Nose/Throat: Musculoskeletal: Present Past Present Past Present Past Poor Circulation Dizziness Gout High Blood Pressure Hearing Loss Arthritis Aortic Aneurism Sinus Infection Joint Stiffness Heart Disease Nosebleed Muscle Weakness Vascular Disease Sore Throat Osteoporosis Heart Attack Difficulty Swallowing Broken Bones Chest Pain Bleeding Gums Joints Replaced High Cholesterol Pace Maker Eyes: Endocrine: Jaw Pain Present Past Present Past Irregular Heartbeat Glaucoma Thyroid Disease Swelling in Legs Double Vision Diabetes Blurred Vision Hair Loss Genitourinary: Menopausal Present Past Integumentary: Menstrual Problems Kidney Disease Present Past Lower Side Pain Skin Lesions Psychiatric: Burning Urination Skin Ulcers Present Past Frequent Urination Skin Disease Depression Blood in Urine Eczema Anxiety Disorder Kidney Stone Psoriasis Unusual Stress Rashes Hematologic/ Constitutional: Lymphatic: Present Past Allergic/ Present Past Hepatitis Immunologic: Present Past Weight Loss/Gain Blood Clots Hives Energy Level Problem Cancer Immune Disorder Difficulty Sleeping Easy Bruising HIV/AIDS Easy Bleeding Allergy Shots Neurologic: Fevers/Chills/Sweats Cortisone Use Present Past Babinski Respiratory: Stroke Present Past Gastrointestinal: Seizures Asthma Present Past Head Injury Tuberculosis Gallbladder Problems Dementia Shortness of Breath Bowel Problems Brain Aneurysm Emphysema Constipation Numbness Cold/Flu Liver Problems Severe Headaches Cough/Wheezing Ulcers Pinched Nerves Diarrhea Parkinsons's Disease Nausea/Vomiting Carpal Tunnel Bloody Stools Spinning Balance Poor Appetite
5 MEDICATIONS Please list current medications, dosage, and frequency. ne Medication Dosage Frequency Medication Dosage Frequency Please list any known allergies to medications ne SMOKING Do you smoke tobacco of any kind? Yes, currently Former smoker Never been a smoker If yes, how often do you smoke? Everyday Sometimes If yes, what is your level of interest in quitting smoking? CURRENT HEALTH CONDITIONS Has any doctor diagnosed you with Hypertension presently? Yes If yes, please describe: Has any doctor diagnosed you with Diabetes presently? Yes What kind? Type 1 Type II If yes, was your blood lab-work test for hemoglobin A1c>9.0%? Yes t sure If yes, other comments regarding Diabetes: Briefly list any other main health problems: Have you had an X-ray or CT scan or MRI of your low back spine in the past 28 days? Yes TO BE PERFORMED BY CLINIC STAFF Height: inches Weight: pounds BP: /
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