Chiropractic Case History/Patient Information. Social Security # Home Phone: Address: City: State: Zip: address: Fax # Cell Phone:

Transcription

1 Chiropractic Case History/Patient Information 1 Date: Patient # Doctor: Tassin Name: Social Security # Home Phone: Address: City: State: Zip: address: Fax # Cell Phone: Age: Birth Date: Race: Marital: M S W D Occupation: Employer: Employer's Address: Office Phone: Spouse: Occupation: Employer: How many children? Names and Ages of Children: Name of Nearest Relative: Address: Phone: How were you referred to our office? Family Medical Doctor: When doctors work together it benefits you. May we have your permission to update your medical doctor regarding your care at this office? All payment is due at time of service. Currently we do not take Medicare, Insurance, OR Workers Comp. The patient understands and agrees to allow this chiropractic office to use their Patient Health Information for the purpose of treatment, payment, healthcare operations, and coordination of care. We want you to know how your Patient Health Information is going to be used in this office and your rights concerning those records. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information we encourage you to read the HIPAA NOTICE that is available to you at the front desk before signing this consent. The following person(s) have my permission to receive my personal health information: Patient's Signature: Guardian's Signature Authorizing Care: Date: Date:

2 PATIENT NAME DATE HISTORY OF PRESENT AND PAST ILLNESS: Doctor: Brian J Tassin, D.C. PAGE2 Main Problem What pain causes you to come to the office? How did this pain begin or occur? When did this pain start? How long does this pain last? How bad is this pain? (Circle one - 1= mild pain - 10= intense pain) Circle the word or words that best describe the pain: Cramping Aching Dull Sharp Shooting Bright Diffuse Lightening-like Throbbing Nagging Burning Deep Stinging Pressure-like How often does the pain occur? (Circle one) Occasional Frequent Constant Does this pain travel to any other area? What makes this pain better? What makes this pain worse? What else have you done to treat this pain? Have you ever had the same or a similar condition? Yes No If yes, when and describe: Days lost from work: Date of last physical examination: Do you have a history of stroke or hypertension? Have you had any major illnesses, injuries, falls, auto accidents or surgeries? Women, please include information about childbirth (include dates): Have you been treated for this same, or any health condition by a physician in the last year? Yes No If yes, describe: What medications or drugs are you taking? Do you have any allergies to any medications? Yes No If yes, describe: Do you have any allergies of any kind? Yes No If yes, describe: Do you have any Congenital (genetic) Condition? Yes No If YES, Describe: Women: Are you pregnant? Last KNOWN Menstrual Period: / / Have you ever been to a Chiropractor? Yes No If YES, Describe

3 Have you had or do you now have any of the following symptoms/conditions? Place and X or checkmark on the line & indicate with the letter (N) if you have these conditions now, or (P) if you have had these conditions previously. N = Now P = Previously Headaches Frequency Loss of Balance Neck Pain Fainting Stiff Neck Loss of Smell Sleeping Problems Loss of Taste Back Pain Unusual Bowel Patterns Nervousness Feet Cold Tension Hands Cold Irritability Arthritis Chest Pains/Tightness Muscle Spasms Dizziness Frequent Colds Shoulder/Neck/Arm Pain Fever Numbness in Fingers Sinus Problems Numbness in Toes Diabetes High Blood Pressure Indigestion Problems Difficulty Urinating Joint Pain/Swelling Weakness in Extremities Menstrual Difficulties Breathing Problems Weight Loss/Gain Fatigue Depression Lights Bother Eyes Loss of Memory Ears Ring Buzzing in Ears Broken Bones/Fractures Circulation Problems Rheumatoid Arthritis Seizures/Epilepsy Excessive Bleeding Low Blood Pressure Osteoarthritis Osteoporosis Pacemaker Heart Disease Stroke Cancer Ruptures Coughing Blood Eating Disorder Alchoholism Drug Addiction HIV Positive Gall Bladder Problems Ulcers SOCIAL HISTORY Please indicate beside each activity whether you engage in it: OFTEN= O SOMETIMES= S NEVER= N Vigorous Exercise Moderate Exercise Alcohol Use Drug Use Tobacco Use Caffeine Family Pressures Financial Pressures Other Mental Stresses Other (specify) High Stress Activity

4 Please answer all of the following questions to help us determine possible risk factors: (Place an X in the box if the answer is yes, leave blank in the answer is no. Question Yes Question Yes Have you ever had an adverse reaction to chiropractic care? If you have neck pain or headache, does this pain seem unlike anything you have experienced before? Have you ever been diagnosed with any of the following? -Compression fracture(s) of the spine? -Osteoporosis? -Spinal stenosis? -Cancer? Rheumatoid arthritis, Reiter's syndrome, Anklyosing Spondylitis, Gout, or Psoariatic arthritis? -Osteogensis imperfecta? -Ligamentous hypermobility? Do you bruise easily? Do you bleed for long periods of time after a cut? Do you currently have any infections? Do you have diabetes or kidney disease? Do you take aspirin on a regular basis? Do you take warafin (coumadin), heparin, or other similar blood thinners? Have you ever become dizzy or lost consciousness when turning your head? Have you ever had a TIA or stroke? Do you take corticosteroids? Have you had spinal surgery? Have you had any of the following problems? - Recent inability to urinate or lack of control when urinating? - Numbness in the genital area? - Sudden weakness in the arms or legs? Have you ever had inflamed veins or blood clots? Do you have any metal implants? Do you have uncontrolled high blood pressure? Do you have any skin conditions? PLEASE USE THIS SPACE TO SUPPLY ANY ADDITIONAL PERTINENT INFORMAITON REGARDING YOUR CONSITION OR HEALTH HISTORY:

5 PATIENT NAME DATE Doctor: Tassin FAMILY HISTORY Please review the below-listed diseases and conditions and indicate those that are current health problems of the family member. Leave blank those spaces that do not apply. Circle your answers if your relative lives around this locality, as some hereditary conditions are affected by similar climate. CONDITION Arthritis Asthma-Hay Fever Back Trouble Bursitis Cancer Constipation Diabetes Disc Problem Emphysema Epilepsy Headaches Heart Trouble HighBlood Pressure Insomnia Kidney Trouble Liver Trouble Migraine Nervousness Neuritis Neuralgia Pinched Nerve Scoliosis Sinus Trouble Stomach Trouble Other: FATHER MOTHER SPOUSE BROTHER(S) SISTERS CHILDREN ME If any of the above family members are deceased, please list their age at death and cause: I certify the information provided is complete and accurate to the best of my knowledge: Name of Patient Signature of Patient/Legal Guardian Date Thank You, Please ensure all blanks are filled out or you have indicated n/a for each question above.