Patient Medical History
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- Loren Gibbs
- 5 years ago
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1 #3 1810, 8 th Street East, Saskatoon SK S7H0T6 Phone (306) Fax (306) Michelle Kormos, Osteopathy (current study) Patient Medical History Please complete the entire medical history and write N/A in any section that is not applicable. Name: Date: Home Phone Number: Work Phone Number: Cell Number: Mailing Address: Date of Birth: Age: Today s Visit Reason for seeking treatment: Is it possible the pain or injury is related to a specific incident? NO YES Date of incident: 1
2 Draw the location and type of your pain on the body outlines and mark how intense the pain is on the scale. Other Care Practitioners List all doctors, therapists, etc. that you are currently seeing and frequency of visits Medications: List medications you are taking now (including vitamins, Aspirin, Tylenol, Advil, etc.) the reason for each and the name of doctor who prescribed or recommended it: Medications: Who prescribed it: Purpose of Medication: Allergies to medications: Other Allergies: 2
3 Neurological Health: Please check if you have had any of these and give age of onset, frequency of incident and details. fainting spells Dizziness Equilibrium/Balance Motion Sickness Tinnitus (ear ringing) Hearing Loss Vision Problems Memory Problems Attention/Concentration Problems Weakness in Extremities Burning in Extremities Numbness in Extremities Cramps in Extremities Difference between sides of body Other Have you had any diagnostic tests done (eg.x-ray, EMG, Cat scan, MRI)? If yes, please give doctor s name, where the test was done, approximate date, and results Ear/Nose/Throat Please check if you have had any of the following and give the age and onset and frequency or list as ongoing Ear infections Tinnitus Tubes in ears Recurring sore throat Sinus congestion Sinusitis Allergies Tonsillitis Strep Throat Mouth breather Other ear/nose/throat dysfunction 3
4 Digestive Health Please check if you have had any of these and give age and onset and frequency or list as ongoing Ulcer/ Stomach Problems Acid reflux H Pylori infection Obesity Underweight Diarrhea Constipation Hemorrhoids Hiatus Hernia Chrohn s disease Colitis Irritable bowel syndrome Gallbladder problems Liver problems Pancreas problems Other Urinary Health Bladder Problems Kidney Problems Urinary Tract Infections Incontinence Other Cardiovascular Health Anemia Diabetes Hypoglycemia High Blood Pressure Low Blood Pressure Heart Problems Other 4
5 Respiratory Health Asthma Had wind knocked out of you Difficulty breathing Bronchitis Pneumonia Croup Whooping cough Other respiratory problems _ Reproductive History Please circle any of the following you have experienced PMS Menstrual Cramps Heavy Bleeding Infertility Miscarriages Hot Flashes Other: Number of pregnancies Complications: Musculoskeletal Back Problems Neck Problems Scoliosis Bladder Problems Rheumatoid Arthritis Osteoarthritis Other Please list all fractures/breaks/sprains/torn muscles or ligaments and their after effects, if any. 5
6 Cranial/Sacral Injuries Please list all head and tailbone injuries (hit your head, fell on your tailbone, etc.) treatment, after effects. Headaches Age of Onset: Frequency: Where do you feel them?: How long do they last? : Any diagnosis/treatment: Dental & TMJ TMJ/Jaw Problems Tooth Extractions Root Canals Braces Other Surgeries/Procedures Please list all surgeries & procedures with approximate date and your age at the time of the surgery. (include dental work) Immune/Lymphatic Autoimmune disease Hypersensitivity HIV/Aids Other 6
7 Integumentary (Skin) Psoriasis Shingles Athletes Foot Rash Warts Herpes Acne Other Endocrine Diabetes (type 1) Thyroid disorder Other Lifestyle: Please list any habits, interests or hobbies (nail biting, play musical instrument, yoga, hockey, etc.) when you partook in the activity and the duration Do you smoke? No Yes How much? For how long? Quit How long ago? Do you drink alcohol? No Yes How many drinks per day? week? Do you binge drink? Do you take any recreational drugs? No Yes In the past? Please list present and previous occupations and duration Stress Level (1-10) Energy Level (1-10) 7
8 Please list Special Diets: (ie. milk free, low fat, vegetarian, gluten free, etc) What exercising do you do? How often? How long at at time? Please include competitive sports. Sleep: Restful No Yes Number of hours per night? number of times you wake in the night? Reason for waking up? Wake feeling rested? Other Major Life Experiences Please list all other major injuries not mentioned above (car accidents, hospitalizations, falls, sport or play injuries, etc.) Other Health Conditions/Past Illness Please circle any you have had. Measles Rubella (German Measles) Chicken Pox Mumps Thyroid Hypo or Hyper Scarlet Fever Rheumatic Fever Cancer Depression Anxiety Hepatitis A Hepatitis B Infectious Mononucleosis Meningitis Staph Infection Yeast Infection Other: 8
9 Family History Is there any history of the following in your family other than yourself? If yes, please list the family member(s) next to the corresponding condition. Cancer Diabetes Hypoglycemia High Blood Pressure Low Blood Pressure Heart Problems Asthma Other Respiratory Problems Allergies Kidney Problems Gallbladder Problems Weight Problems Headaches Structural Problems (back, neck, etc) Other Please circle Y or N depending on the health of your family member, if N is circled please describe issues/conditions/illnesses. Mother Healthy Y N : Deceased Cause: Father Healthy Y N : Deceased Cause: Siblings # Healthy Y N : Deceased Cause(s): 9
10 Booking Agreement I understand and agree that 24 hours notice is required to change/cancel appointments and I will be responsible for payment of services in full if less than the required 24 hours notice is given. Patient Signature Date Patient Name (printed) Work Waiver Release & Indemnity Agreement I, consent to and authorize Michelle Kormos to administer Manual Therapy treatments. I am aware that all risks of injury to myself are not the responsibility of Michelle Kormos. I understand that Manual Therapy does not replace medical treatment. Michelle Kormos does not provide medical advice, diagnosis or medical treatment. All information provided is for educational and informational purposes and is not meant to substitute for the advice provided by your doctor. I am also aware that there is no guarantee, warranty or assurance has been made to me as to the results that may be obtained. I have certified that I have read and understand this entire informed consent, agree to the above and and agree to be treated. If the patient is a minor I give my consent to have them treated. Signature of patient (or parent/legal guardian): Printed Name: Date: Witness: 10
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Primary Health Concerns Please use the following to best describe the primary reason you are seeking medical care today.
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
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STONEBURNER ACUPUNCTURE, LLC Erin K. Stoneburner, LAc, MAcOM 1135 SE Salmon St, Suite 211 503.784.1660 stoneburner@gmail.com Date: Name: (First) (Middle) (Last) DOB: _ Age: Sex: Address: City/State: ZIP:
ABOUT YOU CHIROPRACTIC EXPERIENCE REASON FOR THIS VISIT ABOUT YOUR SPOUSE HEALTH HABITS
NAME: ABOUT YOU WHO REFERRED YOU TO OUR OFFICE? CHIROPRACTIC EXPERIENCE ADDRESS: CITY: HOME PHONE: STATE/ZIP CODE: CELL PHONE: How did you hear about our office? NEWSPAPER SIGN YELLOW PAGES COMMUNITY EVENT
Patient Health History
Patient Health History Name: (first) (middle) (last) Date: / / Date of Birth: / / Age: Gender: M/F Marital status: S M D W Phone: Email: Children (quantity/age): Mailing Address: 1. Please identify the
Patient Information. How did you hear about the BIHC: If you were referred, please state by whom: If yes, by whom: Date of last visit: DD/MM/YYYY
Dr. Kelly Gillis, ND Doctor of Naturopathic Medicine Patient Information Date of initial appointment: DD/MM/YYYY Name: Address: Age: Date of Birth: DD/MM/YYYY Sex: M F Gender (if different than sex): Occupation:
California Chiropractic Boshears, Inc Yucaipa Blvd., Yucaipa Ca Phone: (909) Fax : (909)
California Chiropractic Boshears, Inc. 35191 Yucaipa Blvd., Yucaipa Ca. 92399 Phone: (909) 790-5005 Fax : (909) 790-5009 Patient Information Date: Name: Address: Home Phone: Work Phone: Sex: Male or Female
DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N)
Medical History: Patient: DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N) List the names of prescription
BROADWAY SPORTS & INTERNAL MEDICINE, P.S TH AVE NE SUITE 202 BELLEVUE, WA P: F:
BROADWAY SPORTS & INTERNAL MEDICINE, P.S. 1600 116 TH AVE NE SUITE 202 BELLEVUE, WA 98004 P: 206 215-2288 F:206 215-2289 MEDICAL HISTORY QUESTIONNAIRE Date Name Date of Birth HT WT Current Medical Complaints
Date of Birth: Age: Sex: male female. Weight: Height: Address: Parents: Mother s Phone: (home) (cell) (work) Mother s
*All information provided is kept in strict confidence Child s Name: Date: Date of Birth: Age: Sex: male female Weight: Height: Girls: Age at first period: Address: Parents: Mother s Phone: (home) (cell)
New Adult Intake Form
New Adult Intake Form Please complete the following form in order to provide us with the background information we require to ensure you receive comprehensive care. Name: Today s Date: Age: Date of Birth
Bahl & Bahl Medical Associates PATIENT MEDICAL HISTORY
Bahl & Bahl Medical Associates PATIENT MEDICAL HISTORY NAME: _ DATE: Please complete the following questionnaire as completely as possible. 1. MEDICAL HISTORY Please list all current and prior health problems,
LECOM Health Ophthalmology
Patient Name: Date of Birth: New Patient Questionnaire Your answers will be used by your healthcare provider get an accurate history of your medical conditions and ocular concerns. If you are uncomfortable