1.0 Presenting complaint: Onset 1.1 When it started? 1.2 How did it start? Progress 1.3 Has the problem increased /decreased so far?
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1 Case history Sr. No. Name Sex M / F Age Marital Status B / S / M / W Occupation Date 1.0 Presenting complaint: Onset 1.1 When it started? 1.2 How did it start? Progress 1.3 Has the problem increased /decreased so far? I / D Site 1.4 Where the pain is located? 1.5 Does it stay in one place? 1.6 Does it move or spread? Severity 1.7 Is it a mere discomfort? 1.8 Is it acute pain which interferes with the activities? 1.9 Whether it keeps him awake at night? Timing 1.10 When did it start? 1.11 When does it come? 1.12 When does it go? Modalities 1.13 What brings it on or worsens it? 1.14 What relieves it? 1.15 What is its relationship with rest & exertion?
2 2 2.0 Respiratory Complaints Reply 2.1 Cough? Dry /Wet 2.2 Sputum? Thin (Watery) /Thick 2.3 Colour of sputum White /Yellow /Greenish / Red 2.4 Blood with cough Yes /No /Occasionally 2.5 Breathlessness 2.6 Chest pain on What brings it? What relieves it? 2.7 Allergies? 3.0 Digestive Complaints: Reply 3.1 Difficulty in swallowing? 3.2 Nausea Vomitting? 3.3 Colour / nature of vomitus? 3.4 Indigestion? 3.5 Constipation? 3.6 Flatulence (Gas)? 3.7 Loose Motions? Colour? 3.8 Sticky / foul-smelling stools 3.9 Mucus / blood in stools? 3.10 Pain in abdomen? 3.11 Nature of Pain? 3.12 What causes pain? 3.13 What relieves Pain? 3.14 Itching in the anus? 3.15 Yesterday s diet Veg or Non-veg 4.0 Cardiovascular Problem: Reply 4.1 Breathlessness? 4.2 Palpitations? 4.3 High BP? 4.4 Chest Pain? 4.5 What causes?
3 3 4.6 What relieves it? 4.7 Odema (Swelling) on feet? 5.0 Bone / Muscle Problem: Reply 5.1 Pain / cramps in muscles? 5.2 Weakness in legs? 5.3 Loss of function /movements? 5.4 Pain in Joints? 5.5 Pain in Joints? One /Many 6.0 Complaints of nervous system: Reply 6.1 Headache? What causes? What relieves it? 6.2 Changes in memory /intelligence? 6.3 Changes in speech / language? 6.4 Paralysis? 6.5 Loss of control over passage of urine 6.6 Loss of control over passage of stools 6.7 Disturbance of Vision Left / Right 6.8 Disturbance of Hearing Left / Right 6.9 Disturbance of Taste 6.10 Disturbance of Smell 6.11 Disturbance of Touch 7.0 Uro-genital Problem: Reply 7.1 Urination Interrupted? 7.2 Urination Burning? Start /End 7.3 Urination Painful Start /End 7.4 Urination Excessive / frequent 7.5 Urination Colour
4 4 8.0 Whether patient had similar problem in the past? 9.0 Family history of this problem or any other problem? 10.1 Treatment seeked / received so far? 10.2 What extent it has helped? 11.0 General Health of the Patient: Reply 11.1 Energy level Good / Fair / Poor 11.2 Immunity status (Birth time) Morning /Afternoon /Night 11.3 Digestion Digestion Good appetite? Digestion Can you eat well? Digestion Regular motions? 11.4 Thirst? Normal / Abnormal 11.5 Urination? Any problem? 11.6 Sleep Sleep Sound sleep? Sleep Refreshing? Sleep Nap in the afternoon? 11.7 Weight Weight Stable? Weight Steadily gaining? Weight Losing weight? 11.8 Addictions Tea/coffee/drink/smoking/tobacco 11.9 Menses Menses Regular Menses Pain free? High BP? Diabetes? When last examined? Diet Diet Break Fast Diet Lunch Diet - Dinner
5 Whether any of the following symptoms were noticed by Patient? If yes (Diabetes) 12.1 Excessive & frequent Urination 12.2 Dryness of mouth & excessive thirst 12.3 Excessive hunger 12.4 Loss of weight 12.5 Weakness, fatigue & body ache 12.6 Mental fatigue & lack of concentration 12.7 Wound infection & delayed healing 12.8 Easy susceptibility to infections of the skin, gums and respiratory system 12.9 Intense itching all over the body, especially that of the genital parts Frequent changes in the sharpness of vision and the spectacle number Numbness of limbs and an abnormal increase or decrease in skin sensations Sexual debility or impotence Diabetic unconsciousness Sudden weigh again after 45 years Coronary heart disease Cerebral haemorrage 13.0 Discuss following factors with Patient to ascertain possibility of BP Hereditary 13.2 Mental tension & approach 13.3 Excessive intake of salt 13.4 Obesity 13.5 Sedentary life 13.6 Smoking 13.7 Alcohol consumption
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For the Patient: Cyclosporine injection Other names: SANDIMMUNE I.V. Cyclosporine (sye kloe spor een) is a drug that may be used to treat certain types of cancer. It may also be used to suppress your immune
KEY TO LIFE CHIROPRACTIC
KEY TO LIFE CHIROPRACTIC REGISTRATION FORM Date Home Phone Cell Phone Email Last Name First Name Middle Initial Street Address City State Zip Sex M F Birth Date Occupation How did you hear about this office?
SLEEP QUESTIONNAIRE. Name: Home Telephone. Address: Work Telephone: Marital Status: Date of Birth: Age: Sex: Height: Weight: Pharmacy & Phone #:
q JHMCE q JHS q SMEH SLEEP QUESTIONNAIRE 1. DEMOGRAPHIC DATA Name: Home Telephone Address: Work Telephone: Marital Status: Date of Birth: Age: Sex: Height: Weight: 2. PHYSICIAN INFORMATION Name of Primary