Tell Us About You. Tell Us Why You re Here
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- Valentine Lambert
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1 Case Number Today s Date CA DC Tell Us About You Title: First: MI: Last: Nickname: Birth date: Age: Sex: Male Female Current address: City: State: Zip: SS #: - - Primary Tel: - - H / W / C Alt. Tel: - - H / W / C Text message provider: In which format do you prefer appointment reminders? (above) Whom may we thank for referring you? Marital status: Single Divorced Widowed Married to: # of children: Ages of children: Employment status: Full-time Part-time Not employed Self Retired Military Occupation: Student: No Full-time Part-time Employer: School name: Alternate address: City: State: Zip: Parents/Other: Emergency Contact: Phone: - - Emergency contact is your: Spouse/partner Parent Other: Tell Us Why You re Here What is the primary reason for your visit? Is this due to a: Automobile accident Work-related injury Personal injury case None When did your pain/symptoms begin (include date if possible)? In your own words and in your own opinion, what do you think the real problem is? The overall severity of your complaints/concerns is: Mild Mild to moderate Moderate Moderately severe Severe The overall frequency is: Occasional Intermittent Frequent Constant If your symptoms change, when are they worse: Morning Afternoon Evening Night NA Get Well Chiropractic DRX Health Questionnaire Page 1 of 5
2 On a Scale of 0-10 (10 Being Unbearable; 0 being No Pain or Discomfort), Please Rate The Following... The HIGHEST your pain gets WITHOUT medication: The LOWEST your pain gets WITHOUT medication: The HIGHEST your pain gets WITH medication: The LOWEST your pain gets WITH medication: Are your symptoms/pain getting: Better Worse Staying the same Is there anything you can do that makes it feel better? Have you had the same or similar problems in the past? No Yes When: Have you had recent treatment for this condition? No Yes please list dates and doctors: What kinds of treatments have you received? Epidural: How Many: When (approx): Physical Therapy: How Long: When (approx): Medication: When (approx): Surgery: Type: When (approx): Other: Use the following key to mark your complaints on the diagram at the right: Pain = P Numbness = N Weakness = W LEFT RIGHT RIGHT LEFT Soreness = O Stiffness = X Swelling = S Burning = B Tingling = T If your complaints include pain, how would you describe it? (please check all that apply): Aching Burning Dull Sharp Shooting Stabbing Throbbing Other: Since your symptoms began, have you noticed any function changes?: Bowel Bladder Sexual No Changes Do work activities aggravate your present complaints? Yes No NA How often does your job involve lifting? Never Occasionally Frequently Constantly Other job requirements (please check all that apply): Bending Carrying Stooping Twisting Turning Walking Other: What is your primary work position? Seated Standing Other: Get Well Chiropractic DRX Health Questionnaire Page 2 of 5
3 Your Activities of Daily Living Please indicate which activities of daily living are compromised by your current state of health: Walking Sitting Climbing stairs Chewing Kneeling Sleeping Standing Lifting children Reading Playing instrument Using telephone Running Bending Lying in bed Using computer Exercising Sitting in recliner Sports Swimming Recreational activities Getting into/out of an automobile Driving a car Riding in a car Other travel Sewing or crafts Doing laundry Making beds Vacuuming Washing dishes Ironing Carrying groceries Caring for pets Cooking Mowing lawn Raking leaves Gardening Shoveling snow Combing hair Shaving In/out of bathtub Brushing teeth Please mark whether you NOW HAVE ( ) or had IN THE PAST ( ) any of the following conditions/illnesses: None apply Allergies Hay Fever Fatigue or Weakness Night Sweats Unexpected Weight Change Jaw Pain/TMJ Sleeping Problems Skin Problems Loss of Balance Dizziness or Lightheadedness Vertigo Fainting Headaches Seizures Loss of Memory Vision Trouble Hearing Trouble Ear Infections Ringing or Buzzing in Ears Loss of Smell or Taste Difficulty Swallowing Difficulty Speaking Weight Issues Sinus Trouble Asthma Wheezing Chronic Cough Shortness of Breath Chest Pain or Pressure Heart Trouble High Blood Pressure Low Blood Pressure Cold Hands or Feet Abdominal Pain Indigestion / Upset Stomach Excess Gas Heartburn Constipation Diarrhea Nausea or Vomiting Bedwetting Urinary Pain or Frequency Kidney or Bladder Trouble Blood in Urine or Stool Menstrual Problems or Pain Prostate Trouble Erectile Dysfunction Fertility Problems Excessive Thirst Thyroid Trouble Anxiety or Nervousness Mood Swings or Irritability Mental or Emotional Difficulty Depression Arthritis Bone Fracture Dislocated Joints Autoimmune Disease Cancer Diabetes Fibromyalgia Multiple Sclerosis Rheumatic Fever Tuberculosis Other: No Conditions/Illnesses Have you lost any time from chores/tasks at home? Have you lost any time from work? Get Well Chiropractic DRX Health Questionnaire Page 3 of 5
4 Sickness, Injury and Accident History *Include DATES, DESCRIPTIONS and specify (R)ight side, (L)eft side or (B)ilaterally as applicable. *Accidents (include automobile, work-related, personal injury, slip and fall, or any serious injury): *Prior illnesses (other than colds and flu): *Surgeries and hospitalizations: Have you had any organs or body parts surgically removed?: No Yes list surgery and dates: Are you currently taking ANY over-the-counter medication: Are you currently taking ANY prescription medication: No Yes list name and for what condition. No Yes list name and for what condition. Remember to list ALL drugs including: aspirin, antibiotics, insulin, birth control pills, blood pressure pills, etc. DRUG CONDITION DRUG CONDITION Your Lifestyle Which of the following best describes your stress level: None Minimal Moderate Extreme Do you smoke? No Yes How much: Do you exercise? No Yes How often: How many caffeinated drinks do you consume: per day How many alcoholic drinks do you consume on average per week (circle): Using a scale from 0 to 10, where 0 equals "awful" and 10 equals "amazing" (please circle): How would you rate your overall health? WOMEN ONLY: To your knowledge are you pregnant? No Yes Due date: If no, are you currently trying to conceive? No Yes Get Well Chiropractic DRX Health Questionnaire Page 4 of 5
5 Other Health Care Providers Have you ever been to a doctor of chiropractic before? No Yes How long ago? Name of previous chiropractor: City: Do you see a medical doctor or osteopath? State: No Yes Date of last visit: Name of medical doctor: City: State: Communication is Key to a Positive Relationship Is there anything else you would like us to know? No Yes To help us ensure clarity of communication, please initial the following: I acknowledge that I was presented with a copy of the Notice of Privacy Practices on my initial visit which describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of Get Well Chiropractic. Our Notice of Privacy Practices is subject to change. The most current Notice of Privacy Practices is on display in the reception room and on Get Well Chiropractic of Northville s website at We encourage you to read it in full. You may obtain additional copies of our most current notice by requesting it from our privacy official, Jenni Gowing. If you have any questions regarding this notice of our health information privacy policies, please contact Jenni Gowing, our privacy official. Get Well Chiropractic may send me birthday cards and holiday greetings. Get Well Chiropractic may send me personal correspondence (e.g. thank you notes, congratulations cards, special event notifications, etc.) To the best of my knowledge the questions on this form have been accurately answered. I understand that providing incorrect or incomplete information can be detrimental to my health. It is my responsibility to inform Get Well Chiropractic of Northville of any changes in my health status. Name of Patient: Date: Personal Representative: Relationship: Signature: Witness: Get Well Chiropractic DRX Health Questionnaire Page 5 of 5
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N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro
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Name Preferred Name First Middle Last Address. Home Phone Cell Phone Carrier. Work Phone Address. Emergency Contact Phone # Relationship
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N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro
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