How frequent are the symptoms present? (#2) Constant (76-100%) Occasional (26-50%)
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- Jonas Todd
- 5 years ago
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1 Name Date Occupation Age Birthdate Sex: M F Previous Chiropractor, if any: Present Concern(s): What bothers you most? (concern #1) Next most? (concern #2) Other Concerns: When did the problem first begin? (concern #1) (concern #2) How frequent are the symptoms present? (#1) Constant (76-100%) Occasional (26-50%) Frequent (51-75%) Intermittent (25% or less) How long does the pain last? (#1) A few minutes A few hours A few days Comes and goes Have you ever experienced these symptoms before? (#1) If yes, approximately how many times? When does the pain occur? (#1) Upon waking Daytime During sleep Depends on position How did your problem begin? (#1) Gradually developed Immediately after a specific incident After multiple incidents Mechanism of Injury (#1): Fall Lifting Sports related Work related Auto accident Other Please explain: What have you done to TRY to relieve your symptoms? (#1) What have you done that WORKS to relieve your symptoms? (#1) What makes your symptoms worse? (#1) Does the pain radiate into another body area? (#1) If yes, where? Is your pain: (#1) Mild Moderate Considerable Severe Please circle the number or numbers which reflect the severity of your pain (#1): Since your problem began, is it (#1): Increasing Decreasing No change How frequent are the symptoms present? (#2) Constant (76-100%) Occasional (26-50%) Frequent (51-75%) Intermittent (25% or less) How long does the pain last? (#2) A few minutes A few hours A few days Comes and goes Have you ever experienced these symptoms before? (#2) If yes, approximately how many times? When does the pain occur? (#2) Upon waking Daytime During sleep Depends on position Mechanism of Injury (#2): Fall Lifting Sports related Work related Auto accident Other Please explain: What have you done to TRY to relieve your symptoms? (#2) What have you done that WORKS to relieve your symptoms? (#2) What makes your symptoms worse? (#2) Does the pain radiate into another body area? (#2) If yes, where? Is your pain: (#2) Mild Moderate Considerable Severe Please circle the number or numbers which reflect the severity of your pain (#2): Since your problem began, is it (#2): Increasing Decreasing No change For #1 AND #2: Do you experience any weakness, pain, numbness, tingling, burning, or other abnormal sensations in your arms, hands, fingers, legs, feet, or toes? Do you experience any symptoms when coughing, sneezing, laughing or having a bowel movement?
2 Have you seen any other health care providers for this condition? YES NO page 2 Date Name Phone Number Please mark on the picture, using letters below, Right Side Back Front Side to indicate the type and location of your sensations or symptoms. (please include all areas of discomfort) A = Ache B = Burning N = Numbness T = Throbbing S = Stabbing or Sharp D = Dull X = Tingling Z = Other Thank you for answering the following questions. A complete understanding of your health status will facilitate proper evaluation and treatment of your complaints. PAST HISTORY List any previous injuries (slips, falls, auto accidents, sports injuries, broken bones, etc., and give dates. Have you had previous neck or back problems? YES NO If so, describe and give dates. List any past significant illnesses and give dates: List any allergies: Are you under another doctor s care for any reason? YES NO If so, give name and condition. List all surgeries and hospitalizations and give dates. YEAR PROBLEM HOSPITAL or CLINIC Are you taking any medications? (Prescription or Non-prescription) If so, please list name and condition treated. FAMILY HISTORY Is there a FAMILY history of serious illness? YES NO If yes, please explain: SOCIAL HISTORY Have you recently been under a significant amount of personal stress? YES NO If yes, please explain: Do you think stress may be contributing to your symptoms? If yes, please explain:
3 Have you ever had any of the following conditions? Please check all that apply: page 3 Angina Anemia Measles Osteoarthritis Smallpox Pleurisy Stroke Bursitis Pneumonia Epilepsy Hayfever Hepatitis: A, B, or C Bronchitis Diphtheria High blood pressure Emphysema Chickenpox Malaria Diabetes Mumps Birth defects Ringing in ears Sinus trouble Thirsty all the time Cold most of the time Warm most of the time Unusually tired Awaken tired/ exhausted Dizziness Incoordination Jumpy or nervous Spinal curvature Wear bifocals Neck frequently cracks Stiff joints upon arising Tuberculosis Rheumatoid arthritis Osteoporosis Osteopenia Hypoglycemia Meningitis Prostatitis Encephalitis Alcoholism Polio Ulcer Eczema Psoriasis Asthma Colitis Gout Ankylosing spondylitis Gallbladder disease Kidney stones Hernia Typhoid fever Food cravings Bruise easily Shingles/ herpes zoster Whooping cough Migraine headaches Headaches Tumor or cancer Heart disease Heart attack Diverticulosis Rheumatic fever Venereal disease Bowel condition Chemical dependency HIV Kidney condition Bladder condition Urinary problems Night sweats Changing mole Blood in stool Blood in urine Thyroid disease Scarlet fever Frequent colds Lupus Other: please specify Do you now or have you recently had a fever? Do you have shortness of breath when NOT exerting yourself? Do you have a phlegm producing cough? If yes, what color is it? Do you have recent hearing changes? If yes, please explain: Do you have recent visual changes If yes, please explain: Do you have nausea? If yes, please explain: Do you have difficulty controlling your bowel or bladder? If yes, please explain: Do you have stomach upset with certain foods? If yes, please explain: Do you have indigestion after meals? If yes, please explain: Do you have a recent change in sexual ability? If yes, please explain: Have you had a recent unexplainable weight change? (gaining or losing) If yes, please explain: Tobacco and Alcohol Use: Has your use of alcohol or other chemicals increased since your symptoms or pain began? Do you smoke? No Yes How much? If you have quit, how long has it been since you quit smoking?
4 Feet (please circle choices) High arches: Right Fallen arches: Right Swollen ankles: Right Use foot / shoe appliance: Right Change of shoes causes / helps relieve pain Bunions: Right Corns: Right Callouses: Right Plantar warts: Right Plantar fasciitis: Right Heel spurs: Right Wear shoes out on outside: Right Wear shoes out on inside: Right Athlete s foot: Right Ingrown toenails: Right Other? Please describe: Have you ever consulted with a podiatrist (foot specialist)? No Yes For what condition? General Information - for Women Only Date of last menstrual period (start) Age menstrual periods stopped If pregnant, number of months Number of pregnancies Number of births Ages of children Are you still menstruating regularly? General Information - for Everyone Who is your medical physician? Who is your dentist? When did you last have a complete physical examination? Results: Where are there scars on your body and briefly the cause: Do you like your pillow? Are you right or left hand dominant? RIGHT Do you carry a child on a hip? If no,why not? LEFT page 4 Do you carry a purse, briefcase, computer bag, backpack, etc. over one shoulder? RIGHT LEFT Please list the dietary, nutritional, and herbal supplements you are taking: Do you consider your diet to be: Why? excellent good fair poor How many servings per day / week do you consume of the following: Fruit Vegetables Whole grains Refined grains Sweets Pop Coffee Tea Milk Water Red meat White meat Fish Eggs Other protein Dairy 1 to 2 3 to 4 5 to 6 Day Week Do you get enough sleep? Do you like your mattress? Hours per night: If no, why not? On a scale of 1 to 10, how much commitment are you willing to give to improve your health?
5 Work and/ or Daily Task Information page 5 Type of work you do: Employer: Please give a brief description of you daily duties: Usual Job Tasks Please circle the approximate percent of time you spend in each of the following activities. Standing 0 % 1-25% 26-50% 51-75% % Sitting 0 % 1-25% 26-50% 51-75% % Walking 0 % 1-25% 26-50% 51-75% % Bending 0 % 1-25% 26-50% 51-75% % Lifting 0 % 1-25% 26-50% 51-75% % Typing 0 % 1-25% 26-50% 51-75% % Computer 0 % 1-25% 26-50% 51-75% % Telephone 0 % 1-25% 26-50% 51-75% % Driving 0 % 1-25% 26-50% 51-75% % Please circle your answers to the following questions: How satisfied are you with your job? Not at all Somewhat Very How rewarding is your job? Not at all Somewhat Very How stressful is your job? Not at all Somewhat Very How noisy is your job? Not at all Somewhat Very Do you work with others who can assist you to perform heavy work? Are there light duty tasks available for you if necessary? Is your present complaint related to a past or present job injury? Yes Past Present No Do you have any special postures or physical demands for work or for recreation? What recreational activities, hobbies, or active interests are you involved in? What do you do for exercise and what is the frequency? Comments:
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Patient Intake Form 30 E. 60 th Street #302 - New York, NY 10022 New Patient Special Consultation Notes: For: (OFFICE USE ONLY) Full Name (First, Last) Date Referral: How did you hear about us? Who should
Chiropractic Applied Kinesiology Vitamins Herbs Homeopathy Health Education Classes PATIENT REGISTRATION
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BACK PAIN QUESTIONNAIRE MELVIN D. LAW, JR., M.D.
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OrthoNeuro For every motion in life. NEW PATIENT INFORMATION NAME: AGE: DATE: REFERRING DOCTOR/THERAPIST: SELF REFERRAL (if so, circle) Are you: Male Female Right handed Left handed Ambidextrous CHIEF
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Family Chiropractic and Wellness. 1 Chiropractic Case History/Patient Information Date: Patient # Name: Social Security # Home Phone: Address: City: State: Zip: E-mail address: Fax # Cell Phone: Birth
Family Naturopathic Clinic
Mark Orbay, B.Sc., N.D. Doctor of Naturopathic Medicine 265 Carling Avenue, Suite 610 Tel: (613) 230-6100 Fax: (613) 230-0070 Name: Phone (Home) Address: (Office) Date of Birth: / / Age: (Month) (Day)
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Vitality Chiropractic & Wellness Center 3348 Tyrone Blvd. St. Petersburg, FL 33710 WWW.DrWyckoff.com Phone (727) 381-7433 Fax (727) 381-7434 Welcome to our office! Please fill out our Health Record as
FLORIDA ORTHOPAEDIC INSTITUTE SPINE FIRST VISIT QUESTIONNAIRE
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Houston Weight Loss and Lipo Centers Patient Name: Address: City, State : Apt: Zip: Email*: *By providing your email address you are agreeing to communication via email. Home Phone Primary contact Work
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WELCOME to the Florence Chiropractic and Wellness Center.
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CHIROPRACTIC CENTER OF ANNAPOLIS 108 Old Solomons Island Rd., Bldg. 2 Annapolis, MD (410) Dr. William J. Boro Dr. Mary X.
CHIROPRACTIC CENTER OF ANNAPOLIS 108 Old Solomons Island Rd., Bldg. 2 Annapolis, MD 21401 (410) 266-5054 Dr. William J. Boro Dr. Mary X. Psaromatis New Patient History Form Patient Name: Date: Please list
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Today s Date: Premier Arthritis and Osteoporosis Center 722 North Fairfield Road Beavercreek, OH 45434 Phone (937) 208-7000 Fax (937) 208-7010 Personal Health Risk Appraisal Last Name: First Name: MI: