PATIENT HISTORY FORM
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1 BodyCheck Prevention & Health Physical Therapy Centre PATIENT HISTORY FORM Please assist us by answering the following questions as completely and accurately as possible. Your answers will assist us by outlining your present symptoms and important medical/injury history, as well as provide us with information that will aid us in the preparation of medical reports requested in the future. Comprehensive history and assessment of your problem is the beginning to successful rehabilitation process. Thank you for your cooperation. Please print clearly and legibly. If you have questions, regarding an item, mark it with a * and your therapist will clarify it. If you need to write more please write on the back of the sheets. NAME: TODAY S DATE: SEX: M F DATE OF INJURY: DATE OF BIRTH: AGE: LIST YOUR PROBLEM AREAS (i.e. neck, lower back, shoulder, etc.) 1. Problem #1 2. Problem #2 3. Problem #3 4. Problem #4 WHERE ARE YOUR SYMPTOMS? Following are body drawings. Please SHADE in the appropriate areas of PAIN, and XXX the areas of NUMBNESS, (pins & needles, tingling), if these words describe your current symptoms. If you do not get these symptoms, please leave the drawings blank. PROBLEM AREAS: Diagrams: Please draw in areas of: PAIN NUMBNESS XXXX
2 BodyCheck Prevention & Health Physical Therapy Centre 2 PROBLEM #1 Did the problem begin suddenly or gradually (over what period of time)? How long have you had this problem? Was there an incident that brought on the problem? (Please describe i.e. how did it start) If the problem is PAIN what is its intensity over the last 24 hours on a pain scale below: 0 (no pain) 10 (the worst pain imaginable) CIRCLE the WORDS that best describe your pain: Superficial or deep Constant or intermittent Increasing, decreasing, or staying the same Worse in the morning or evening Dull ache, sharp, shooting, throbbing Has the pain stayed where it started or has it spread? (Please describe.) What makes your pain WORSE? i.e. sitting, driving, standing, any sports, job duties, etc. Does coughing or sneezing make your pain worse? YES NO Does the pain disturb your sleep? YES NO If YES, does it prevent you from getting to sleep or does it wake you from sleep? (Circle) What makes your pain BETTER? i.e. rest, certain postures or exercises, medications, etc. In what position do you sleep? What type of bed do you sleep on? What type of pillows do you use, and how many? PROBLEM #2
3 BodyCheck Prevention & Health Physical Therapy Centre 3 Did the problem begin suddenly or gradually (over what period of time)? How long have you had this problem? Was there an incident that brought on the problem? (Please describe i.e. how did it start) If the problem is PAIN what is its intensity over the last 24 hours on a pain scale below: 0 (no pain) 10 (the worst pain imaginable) CIRCLE the WORDS that best describe your pain: Superficial or deep Constant or intermittent Increasing, decreasing, or staying the same Worse in the morning or evening Dull ache, sharp, shooting, throbbing Has the pain stayed where it started or has it spread? (Please describe.) What makes your pain WORSE? i.e. sitting, driving, standing, any sports, job duties, etc. Does coughing or sneezing make your pain worse? YES NO Does the pain disturb your sleep? YES NO If YES, does it prevent you from getting to sleep or does it wake you from sleep? (Circle) What makes your pain BETTER? i.e. rest, certain postures or exercises, medications, etc. In what position do you sleep? What type of bed do you sleep on? What type of pillows do you use, and how many? If you have more than 2 problems please ask for more paper and address the above questions again.
4 BodyCheck Prevention & Health Physical Therapy Centre 4 HAVE YOU EXPERIENCED?: (please tick and comment on it if appropriate) CONDITIONS/SYMPTOMS YES NO PAST COMMENTS Dizziness (are you or the room spinning) Nausea/Vomiting Balance problems Change in vision Change in hearing Change in bowel or bladder function Change in sexual function Altered sensation in the groin/crotch region Numbness in the face Ringing or Fullness in your ears Sudden loss of balance, possibly associated with turning your head ( drop attack ) HEADACHES: If you get headaches please fill in the following. When did your headaches start? How often do you get headaches? How long do they last? What is the location of the headache? Does the location change? Where does it start? Where does it spread to? Possible cause of headaches known or unknown? Does medication relieve your headache? Do you have a history of headaches? YES NO (Circle) If YES, are these headaches the SAME or DIFFERENT? In general, is your health: Poor Good Excellent
5 BodyCheck Prevention & Health Physical Therapy Centre 5 Incontinence: Have you ever lost control of your bladder or bowels (leaking urine and/or feces) when: Coughing YES NO Sneezing YES NO Laughing YES NO Exercising YES NO Other times? Do you ever feel the urge to urinate and then are not able to? YES NO Do you need to wear pads in your undergarments to absorb leakage? YES NO If YES, how many pads per day? Do you get pain with bladder/bowel movements or with sexual intercourse? YES NO Is your pain worse during menstruation? YES NO WOMEN: Describe any pregnancies and deliveries including year, problems in pregnancy, the delivery itself, problems after the pregnancy, incontinence, etc. Do you: Smoke cigarettes? Cigars? YES NO If YES: # per day: Smoke a pipe? YES NO If YES: # per day: Take street drugs? YES NO Drink alcohol? YES NO If YES: # per day: Take steroids now/in the past? YES NO Take vitamins/other supplements? YES NO OCCUPATION Please describe your job in relation to the time spent doing what type of activities per day, i.e. 15 minutes per hour of standing, the other 45 minutes sitting. Also, note if you think anything in your work environment influences your injury/pain, i.e. physical setup, task restraints, job demands, stress levels.
6 BodyCheck Prevention & Health Physical Therapy Centre 6 MEDICATIONS: Currently taking. Medications Reason for Medication How long have you been taking them? MEDICAL HISTORY Have you ever been diagnosed with any of the following? ( ) Conditions YES NO Past Comments Cancer Diabetes Heart conditions High blood pressure Thyroid disorders Lung conditions Rheumatoid arthritis Ankylosing spondylitis Other arthritis Epilepsy Fibromyalgia HIV Asthma Anemia Osteoporosis Are you pregnant? Are you amenorrheic? Have you had any other injuries or trauma? Car Accidents? YES NO (If YES, please answer the questions on page #8). Sports Injuries? (please describe) Broken Bones? (please describe) Have you had any recent surgery? (Please describe) Have you had major surgery in the past? (please describe) Do you have: Allergies Metal Implants Pacemaker IUD
7 BodyCheck Prevention & Health Physical Therapy Centre 7 SPECIAL TESTS: Have you had any of these investigative tests done? TEST Area WHEN? DOCTOR RESULTS Examined Month/year To contact for (in brief) if results known X-RAY CT SCAN MRI OTHER; Please specify PREVIOUS TREATMENT: Have you had treatment for previous or for your present injuries? Physical Therapy: When? Where? (optional to answer) Results of Treatment Comments Chiropractic: When? Where? Results of Treatment Comments (optional to answer) Massage: When? Where? Results of Treatment Comments (optional to answer)
8 BodyCheck Prevention & Health Physical Therapy Centre 8 FAMILY/SOCIAL SITUATION Are you married, single, divorced, common-law, other (please circle) Do you have anyone who is dependent on you such as (briefly describe situation): Kids: (ages and number of kids): Elderly Parents that you care for: RECREATION Do you have any hobbies/activities/volunteer work? (Please describe in brief) Do you exercise regularly? (Please describe in brief) MOTOR VEHICLE ACCIDENT INFORMATION (MVA) Please complete only if relevant. Please list DATES of all MVA or accidents that you have been in, (most recent first, then so on) Briefly describe the most recent MVA, i.e. direction of travel, your position in the vehicle, location of impact, airbag deployment, seat belt use, etc. What direction was your head turned? Were you wearing your seat belt? Did your head hit anything? When did your symptoms begin? How did you leave the accident? Did you seek medical attention (when, who, where)? Are there legalities pending?
PATIENT HEALTH HISTORY
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AHI - New Patient Information
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N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro
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CASE HISTORY. Address: City: State: Zip: Date of Birth: Age: address: Occupation: Employer: Spouse's Employer: Referred by:
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BridgeMill Family Healthcare, LLC Date Patient Information Name: Full Mailing Address: Last First MI Phone# (Mobile) (Home) (Work) Email Address Date of Birth: Sex: Male Female SS#: Marital Status: Single
PATIENT INFORMATION HEALTH INFORMATION
PATIENT INFORMATION PLEASE PRINT PATIENTS LAST NAME FIRST NICKNAME STREET ADDRESS APT # TODAYS DATE / / CITY STATE ZIP E-MAIL SEX M F MARITAL STATUS MARRIED SINGLE WIDOWED DIVORCED DOB / / AGE SPOUSES
Chiropractic Case History/Patient Information
Chiropractic Case History/Patient Information 1 Date: Patient # Doctor: Name: Social Security # Home Phone: Address: City: State: Zip: E-mail address: Fax # Cell Phone: Age: Birth Date: Race: Marital:
COMPREHENSIVE PAIN MANAGEMENT INTAKE FORM. Home Phone: Other Contact: Other Contact: Address: City: State: Zip: Address: City: State: Zip:
COMPREHENSIVE PAIN MANAGEMENT INTAKE FORM Last Name: First Name: Middle: Home Phone: Other Contact: Other Contact: DOB: Age: Sex: Name of Referring Physician: Phone: Fax: Address: City: State: Zip: Name
Dr. Gary Malstrom B.Sc.(Hon.), D.C., C.Ac Brant Street, Burlington, Ontario L7R 2J9 (905) Fax (905)
Dr. Gary Malstrom B.Sc.(Hon.), D.C., C.Ac. Personal History: Name: Address: City: Province: Postal Code: Birth date: day /month /year Age: Sex: M F Home Phone: Business Phone: Cell Phone: E-mail: Health
Using the symbols below, please draw in the location of your symptoms on the diagrams. X = Pain 0 = Numbness / = Aching * = Pins & Needles
Date: DOB: Age: Gender: Right handed: Left handed: Who referred you? Is your problem related to : Job injury Date: Car accident Date: Date: Briefly describe your main problem/complaint. Also, describe
Type of Patient and/or payment method (circle one)
Please print # Date: Last Name: First Name: Address: City, State, Zip: Home Phone: Work Phone: Cell Phone: Email address: Date of Birth: Sex: M F Social Security #: Employer name: Occupation: (if a minor,
Area of Complaint: Right Left Bilateral. When did your complaint begin? Unknown Work Accident Auto Accident Sports Injury Other:
Quality Chiropractic 6231 Leesburg Pike Suite 200 Falls Church VA 22044 (703) 237-0404 fax (703) 237-7828 Quality Chiropractic & Rehab 102 Elden Street Suite 12 Herndon VA 20170 (703)581-8999 fax (703)
Today s Date: Date of Birth: Age: Height: Weight: Who Referred: If not referred, how did you choose this office? Why are you seeing the doctor today?
Name: Today s Date: Date of Birth: Age: Height: Weight: PCP: Who Referred: If not referred, how did you choose this office? Why are you seeing the doctor today? Please list major complaint(s) and describe
Arizona Injury Medical Associates, P.L.L.C. Physiatry Care
GENERAL INFORMATION HISTORY QUESTIONNAIRE Name: Today s Date: Age: Date of birth: Sex: M F SS#: Home Address: Cell Phone: Your doctor: Home Phone: Your Attorney (if any): If questions arise after today
Please indicate where your present pain level is by circling the number that best describes the intensity: No Pain Mild Moderate Severe
Date: Specific Date of Onset: Please indicate where your present pain level is by circling the number that best describes the intensity: No Pain Mild Moderate Severe 0 1 2 3 4 5 6 7 8 9 10 Your insurance
Name: Date: DOB: Full Address: Phone: Home: Cell: Occupation: Emerg. contact and phone: Relationship to pt.
Client Registration Name: Date: DOB: Email: Full Address: Phone: Home: Cell: Occupation: Emerg. contact and phone: Relationship to pt. How did you hear about ALIGN? ALIGN Integration Movement does not
APPLICATION FOR CARE AT OPTIMAL HEALTH CHIROPRACTIC
Today s Date: APPLICATION FOR CARE AT OPTIMAL HEALTH CHIROPRACTIC PATIENT DEMOGRAPHICS Name: Birth Date: / / Age: Male Female Address: City: State: Zip: E-mail Address: Home Phone: Cell Phone: Martial
BalanceChiropractic 7165 E University Dr. Suite 102 Mesa, AZ
BalanceChiropractic 7165 E University Dr. Suite 102 Mesa, AZ 85207 480.830.0175 Health History Name Address City State Zip Day Phone Evening Phone E-mail Address Employer Birth Date Age Gender Emergency