Introduction Patient Case History
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1 Introduction Patient Case History Date: PATIENT INFORMATION Name: (First MI Last) Preferred Name: Street: Apt.: City: State: Zip: Social Security #: Date of Birth: Gender: M F Martial Status: [ ] S [ ] M [ ] W [ ] D [ ] O Spouse: Children: None _ Who Referred you to this office? (Name) Language: English / Spanish / Indian / Japanese / Chinese / Race/Ethnicity: White / American Indian or Alaska Native/ French / German / Russian / Other Asian / Native Hawaiian/Other Pacific Islander / African American / Hispanic or Latino / Decline to Answer CONTACT INFORMATION Home Ph: Work Ph: Cell Ph: Cell Carrier: Hm: Wk: _ Preferences: Home Ph / Work Ph / Cell Ph / Hm / Wk / Postal Mail Emergency Contact: Phone: Primary Physician: Phone: Student Status: Full Student Part Student Non-Student Highest level of Education: High School College Grad. Post Grad. Employed: No Yes (Details below) Occupation: Employer: Employers Address: Street City State Zip FINANCIAL INFORMATION Is today s visit the result of an accident? No Auto Work Other: Will we be working with insurance? No Yes (Details) A copy of your insurance card[s] will be made, in addition, please complete the information requested below: Primary: ID#: Secondary: ID#: Where would you like statements sent? Self Other (Details below) Other than Self: - (Relationship) Full Name: Phone: Address: City: State: Zip: It is Usual and Customary to Pay for Services as Rendered Unless Otherwise Arranged 1 Intro Patient Case History 2018
2 HISTORY OF PRESENT ILLNESS HISTORY OF PRESENT ILLNESS (Please describe) Describe Major Complaint: Secondary Complaints: When did it start? / / What happened? Which daily activities are being affected by this condition? MAJOR COMPLAINT Location of Symptoms and Radiation Quality: Previous Treatment: Sharp None Stabbing Chiropractor Burning Medical Doctor Achy Physical Therapy Dull ER/Urgent Care Stiff & Sore Orthopedic Does it radiate? Previous Diagnostic Testing: No Yes (Please indicate on drawing) None Improves with: X-Rays Ice MRI Grade Intensity/Severity: Heat CT None (0/10) Movement Mild (1-2/10) Stretching *Women: Are you pregnant? Mild-Moderate (2-/10) OTC Medications: No Last Menstrual Period: / / Moderate (-6/10) Yes Due Date: / / Moderate-Severe (6-8/10) Worsens with: Present Illness Comments: Severe (8-10/10) Sitting Frequency: Standing/Walking Off & On Lying Down/Sleeping Constant Overuse/Lifting Prescription Medications & Supplements: None Allergies to Medications: No known drug allergies Yes (List- Name, dosage, frequency) Yes (List- Name and reaction) 2 Intro Patient Case History 2018
3 Mother Father Sibling1 Sibling2 Sibling3 Sibling Child1 Child2 Child3 PAST MEDICAL HISTORY PAST, FAMILY, AND SOCIAL HISTORY Have you ever had any of the following? (Please select all that apply and use comments to elaborate.) Illnesses: Hospitalizations: (Non-surgical with Date) Medical History Comments: Asthma _ Autoimmune Disorder (type) Blood Clots Surgeries: (If yes, provide type & Surgery date) Cancer (Type) Cancer CVA/TIA (stroke) Orthopedic Diabetes Shoulder- R / L Migraine Headaches Elbow/Forearm - R / L Osteoporosis Wrist/ Hand - R / L Hip - R / L Knee - R / L Ankle/Foot - R / L Injuries: Spinal Surgery Back Injury Neck: Broken Bones Back: Head Injury Neck Injury Falls FAMILY HISTORY (Please mark X to all that apply and use comments to elaborate.) Unknown Unremarkable Family History Comments: Age at Death (if Deceased) SOCIAL AND OCCUPATIONAL HISTORY Do you live: Alone With Spouse With Dominant Hand: Right Left Ambidextrous Smoking/Tobacco Use: If current smoker, amount = Caffeine Use: No Yes How often: Every day Some Days Former None What kind of Caffeine? Drug Use: None Recreational User Addiction Alcohol Use: Gender F M Aneurysms CVA(Stroke) Cancer Diabetes Heart Disease Hypertension Other Family History None Casual Moderate Heavy < 3 drinks/day 3-6 drinks/day > 6 drinks/day Coffee Tea Energy Drinks Soda Exercise Frequency: Never Daily Weekly Walks Drinks Wine Drinks Beer Runs Swims Social History Comments: 3 Intro Patient Case History 2018
4 Are you currently experiencing any of these symptoms? (Check all that apply) Many of the following conditions respond to Chiropractic and Acupuncture treatment. General: (constitutional) Recent Weight Change Fever Fatigue Musculoskeletal: Low Back Pain Mid Back Pain Neck Pain Arm Problems Leg Problems Painful Joints Stiff/Swollen Joints Sore/Weak Muscles or Joints Muscle Spams/Cramps Broken Bones Neurological: Numbness or tingling sensations Loss of Feeling Dizziness or Light Headed Frequent or Recurrent Headaches Convulsions or Seizures Tremors Stroke Headaches Have you ever had a head injury? Ever been in an auto accident? Mind/Stress: Nervousness Sleep Problems Memory Loss or Confusion _ Genitourinary: Sexual Difficulty Kidney Stones Burning / Painful Urination Change in force / strain with urinatio Frequent Urination Blood in Urine Incontinence or Bed Wetting Gastrointestinal: Loss of Appetite Blood in Stool Change in Bowel Movements Nausea or Vomiting Abdominal Pain Frequent Diarrhea Constipation Eating Disorder Other: Cardiovascular & Heart: Chest Pains Rapid or Heartbeat change Swelling of Hands, Ankles or Feet Heart Problems Blood Pressure Problems BLOOD PRESSURE PROBLEMS: Are you currently being treated? Yes No IF YES, Who is treating you? Respiratory: Difficulty Breathing Coughing Blood Persistent Cough Asthma or Wheezing Lung Problems Ears, Nose and Throat: Bleeding gums/ Mouth Sores Bad Breath or Bad Taste Dental Problems Swollen Throat or Voice Change Swollen Glands in Neck Ringing in the Ears Ear - Ache/Ringing/Drainage Sinus / Allergy Problems Nose Bleeds Hearing Loss Endocrine, Hematologic, and Lymphatic: Thyroid Problems Diabetes Excessive Thirst or Urination Cold Extremities Heat or Cold Intolerance Change in hat or glove size Dry Skin Glandular or Hormone Problem Swollen Glands Anemia Easily Bruise or Bleed Phlebitis Transfusion Immune System Disorder Integumentary: (Skin, Nails, & Breasts) Rash or Itching Change in Skin Color, Hair, or Nails Non-healing Sores or Lesions Change of appearance of a mole Breast Pain, Lump, or Discharge Eyes and Vision: Wear Contacts/Glasses Blurred or Double Vision Glaucoma Eye disease or Injury Women Only: Infertility Painful or Irregular Periods Vaginal Discharge Pregnancies with Outcome & Date Allergic/ Immunologic: Food Allergies Environmental Allergies Other: Comments: I have read the above information and certify it to be true and correct to the best of my knowledge, and hereby authorize this office to provide me with health care, diagnostic testing, and/or therapeutic services, in accordance with this state's statutes. Patient or Guardian Signature Date Treating Doctor Signature Date Thank you for your cooperation! Questionnaire 2018
5 Functional Rating Index In order to properly assess your condition, we must understand how much your problems have affected your ability to manage everyday activities. For each item below, please circle the number which most closely describes your condition right now. 1. Pain Intensity 6. Recreation No Mild Moderate Severe Worst pain pain pain pain possible pain Can do Can do Can do Can do Cannot all most some a few do any activities activities activities activities activities 2. Sleeping Frequency of pain 0 1 Perfect Mildly Moderately Greatly Totally sleep disturbed disturbed disturbed disturbed sleep sleep sleep sleep 3. Personal Care (washing, dressing, etc.) 0 1 No Mild Moderate Moderate Severe pain; pain; pain; need pain; need pain; need no no to go slowly some 100% restrictions restrictions assistance assistance. Travel (driving, etc) No Occasional Intermittent Frequent Constant pain pain; pain; pain; pain; 25% 50% 75% 100% of the day of the day of the day of the day 8. Lifting 0 1 No Increased Increased Increased Increased pain with pain with pain with pain with pain with heavy heavy moderate light any weight weight weight weight weight 9. Walking 0 1 No Mild Moderate Moderate Severe No pain; Increased Increased Increased Increased pain on pain on pain on pain on pain on any pain after pain after pain after pain with long trips long trips long trips short trips short trips distance 1 mile 1/2 mile 1/ mile all walking 5. Work 10. Standing Can do Can do Can do Can do Cannot usual work usual work; 50% of 25% of work plus unlimited no extra usual usual extra work work work work No pain Increased Increased Increased Increased after pain pain pain pain with several after several after after any hours hours 1 hour 1/2 hour standing Name PRINTED Signature Date Total Score excel.funct
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New Patient Medical History and Intake Form Medical Marijuana ( MMJ ) Certification
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Welcome to Compass Chiropractic!
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Patient Interview Form
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CHIROPRACTIC INTAKE FORM
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PATIENT HEALTH QUESTIONNAIRE Radiation Oncology
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Patient Interview Form
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Southern Maine Integrative Health Center Adult Intake Form
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N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro
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Johanna M. Hoeller, DC PS
ENTRANCE FORM Birth date: Height: Weight: Emergency Contact: Emergency Contact Phone: ( ) Spouse/Partner or Parent s name: Children s names: Occupation (Your): Employer: Address: City/State/Zip: Phone:
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New Patient Intake Form
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Patient Registration Form
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