PLEASE DESCRIBE YOUR PRIMARY HEALTH CONCERNS

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Elijah Hampton
5 years ago
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1 Dr. Kenzie Maloy, DC, DABCI, DACCP, DACBN 505 E. Main St. Suite B Hermiston, OR Phone: Fax: PERSONAL INFORMATION: First Name: Last Name: Middle Initial: for doctor communications: Female / Male Race/National/Ethnic Roots: Place of Birth: Right Handed / Left Handed / Mixed Dominance Age: Birth Date: SOCIAL HISTORY Marital status: Single Married Divorced Widowed Religious Preference: Where do you live: House Apartment Nursing Home Assisted living Homeless Who lives with you?: Work status: (check one) Employed Unemployed Retired Disabled Current and prior occupations: Highest level of education: Age and gender of children (if any): GENERAL: Who can we thank for referring you? What do you hope to get from today s visit? PLEASE DESCRIBE YOUR PRIMARY HEALTH CONCERNS Is the condition due to injury or sickness arising out of employment? Is the condition due to injury or sickness arising out of an auto or type of accident? Number of days lost from work Date symptoms appeared or accident happened 1. What are the primary problems you are experiencing? 2. In the past have you ever had the same or a similar condition? yes no If yes, please describe: 3. Has it changed recently? Better Worse Same What types of treatment have you tried? What makes it better? Worse? 4. How frequent is the condition? 5. Is this affecting your sleep? Yes No If yes, please describe: How long does it last? 1

Is this affecting your ability to perform your job or daily activities? Yes No If yes, please describe: 6. Are there any symptoms that may be related to these concerns, which you have not listed?

If possible list the approximate date of the last visit and their city and telephone number. 1. 2. 3. 4. Please describe any previous tests (X-ray, MRI, EKG, blood work, etc.

2 Is this affecting your ability to perform your job or daily activities? Yes No If yes, please describe: 6. Are there any symptoms that may be related to these concerns, which you have not listed? If yes, please describe: Yes No Please list all doctors you have seen related to your current concern, also please include any chiropractors or family medical doctors. If possible list the approximate date of the last visit and their city and telephone number Please describe any previous tests (X-ray, MRI, EKG, blood work, etc.) to investigate your current problems. Please mark an X on the line to indicate the severity of your condition: No symptoms Does not interfere with activities Extreme symptoms Disabling Please mark any areas of concern on the diagrams below. N Numbness S-stabbing. Indicate any problems as best you can. P- pins & needles B- burning A- aching Major Health Problems with brief description Date of Onset Frequency (Daily, weekly) Severity (mild, mod or severe)

3 OTC & Prescription Medications DOSEAGE and # per day Good No Bad Bad then Good Allergies (either to medications, substances, airborne) I hereby authorize payment directly to Pinnacle Natural Health Center for insurance benefits. I understand I am financially responsible for all services rendered to the patient. Patient balances are to be paid at the time of service. I hereby give my express written consent to Pinnacle Natural Health Center and any of it s agents to communicate with me regarding my account(s) through various means of communication including but not limited to cellular phone, landline, text or similar electronic devices. This express consent is given in order to permit Pinnacle Natural Health Center to more easily communicate regarding any issue; including for purposes of billing, insurance and collection of any balance due. Signature: Date: 3

4 DIETARY HISTORY Check the most appropriate description below of my diet: Mostly carbohydrates (bread, pasta, etc.) Mostly dairy (milk, cheese, etc.) Mostly meat Mostly vegetarian (vegetables, fruits, grains, etc.) Describe: Are you on a Gluten Free Diet Yes No Are you on a Dairy Free Diet Yes No Have you benefited by being on this diet? Are you on a Low Carbohydrate Diet? Are you on high Omega 3 fatty acid supplementation? Yes No. Any benefits? Please list the foods and beverages normally consumed by you for three typical days: DAY 1 DAY 2 DAY 3 DIGESTIVE HEALTH Do you have periodic loose stools/diarrhea Yes No Offensive Gas Yes No Undigested Food in Stools Yes No Offensive Breath Yes No Do you suffer with acid reflux/heartburn Yes No Are you currently taking an acid-blocking medication such as Tagamet, Pepcid, etc. Yes No Do your digestive problems occur more with stress Yes No Unsure Do you produce well formed stools Yes No Have you ever produced formed stools Yes No ANTIBIOTIC HISTORY How many courses of antibiotics have you received in lifetime (approx): Main reason for antibiotic use: Ear Infections Bronchitis Pneumonia Sinus Infection Intestinal Infection (please explain) Have you ever been treated for a yeast infection following antibiotic use 4

5 Survey of Your Health History Please circle all that apply. Indicate whether this is a Current (C) or Past (P) concern also provide an approximate date for past concerns. Indicate severity with 1 mild, 2 moderate, 3 severe. 1. General Fever 4. Cardiovascular 9. Women Only difficult periods Night sweats irregular heartbeat hot flashes Nervous ness racing heart irregular cycles Bleeding chest pain breast pain Diabetes high blood pressure lump in breast Thyroid swelling difficulty becoming pregnant Headache prior heart problem complications of pregnancy Fainting pacemaker Depression stroke Date last period ended Memory loss Date last gynecologic exam _ Chills 5. Musculoskeletal 10. Men Only Fatigue stiffness testicular pain Weight loss/gain pain prostate problems Anemia swelling difficult erection Cancer spinal curve low sperm count Substance abuse arthritis 11. Exercise Dizziness weakness none Seizures twitching 1-2 per week Phobias tremors 3-4 per week Waking in night numbness 5-7 per week Problems falling asleep What type? Explain any surgeries or 6. Skin 12. Habits hospitalizations: rashes Smoke ( packs/day, years? ) mole changes Alcohol ( drinks per wk) itching Caffeine ( cups per day) Any broken bones, car accidents or nail changes Recreational drug use injuries? redness 13. Family Are your parents living? 2. Gastrointestinal belching/gas 7. EENT blurry vision If so do you consider them to be in good health? vomiting double vision Ages: M Father bloody stools eye pain hernia jaw pain Circle any below that apply to constipation hearing loss your parents, grandparents, siblings or diarrhea abdominal pain ringing in ears ear infection children: Diabetes nausea sinus problems Stroke liver problems nosebleeds Hypertension throat problems Cancer 3. Respiratory breathing problems speech problems Glasses or contacts? Seizures Tremors spitting phlegm/blood 8. Genitourinary Brain disorder allergies frequent/painful urination Heart disease asthma incontinence Lung disease shortness of breath blood in urine or stool Arthritis chronic cough urinary infection Scoliosis pneumonia venereal infection 5

CASE HISTORY. Address: City: State: Zip: Date of Birth: Age: address: Occupation: Employer: Spouse's Employer: Referred by:

CASE HISTORY. Address: City: State: Zip: Date of Birth: Age: address: Occupation: Employer: Spouse's Employer: Referred by: CASE HISTORY Account #: Please complete this form using your keyboard, then print it using the print function of your browser. You can then sign the form and bring it with you to your first appointment.