TOUCHMATTERS MANUAL THERAPY Health History Form NAME: DATE: ADDRESS: (street and number) (city) (postal code) TELEPHONE: (home) (work) (cell)
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1 TOUCHMATTERS MANUAL THERAPY Health History Form The information that you are providing on this form will give me the necessary starting point to help you with your primary complaint. Please be as thorough as you can, if there is something that you feel I should know about your health history and there is no space for it on the form please add it to the last page. When I meet with you we will go over the information that you have provided and gather more detail if needed. NAME: DATE: ADDRESS: (street and number) (city) (postal code) TELEPHONE: (home) (work) (cell) DATE OF BIRTH: OCCUPATION: DOCTOR S NAME: PHONE # ADDRESS: WHO REFERRED YOU TO ME FOR CARE? Please check off the conditions that you currently experience CARDIOVASCULAR RESPIRATORY INFECTIONS high blood pressure / shortness of breath herpes low blood pressure / chronic cough warts angina bronchitis frequent colds heart disease pneumonia frequent flu s rheumatic fever sinusitis other phlebitis tuberculosis chest pains asthma / emphysema auto immune disease stroke smoker (light / heavy) varicose veins allergies athletes foot poor circulation ( food,nuts, perfumes ) candida cold sores DIGESTIVE /UROGENITAL MUSCULAR / JOINTS poor appetite neck pain/stiffness ( L / R ) regular meals face pain ( L / R ) bloating /difficult digestion head pain ( L/ R/ front/ back ) constipation TMJ pain/stiffness ( L /R ) diarrhea shoulder pain/stiffness ( L / R ) liver dysfunctions arm pain/stiffness (L / R ) gall bladder dysfunctions hand pain/stiffness (L / R ) Touch Matters - Rev. 09/2013 1
2 diabetes back pain/stiffness ( upper, middle, lower ) IBS diagnosis pelvis/hip pain/stiffness ( L / R ) celiac disease upper legs pain/stiffness ( L / R ) crohns disease knees pain/stiffness ( L / R ) colitis lower leg pain/stiffness (L / R ) bowel movements (per day) ankle/foot pain/stiffness ( L / R ) more osteoarthritis osteoporosis SKIN rheumatoid arthritis acne fractures herpes implants: pins, wires screws, other fungal infections scars HEAD / FACE rashes headaches (migraine / tension / cluster /sinus ) eczema per day per week per month psoriasis head trauma (Y / N ) face or head lacerations easily bruised concussion blow to head saw stars impaired skin sensation dizziness forget details of injury low energy skin infection of any kind more emotional constant headache topical medications vision problems earaches ringing eye pain dry eye excessive tearing photosensitive other reduced hearing epilepsy nausea vertigo /spinning sensation vision problems contact lenses NERVOUS SYSTEM dental history: extractions root canals implants sciatica braces wisdom teeth extracted thoracic outlet syndrome broken teeth false teeth carpal tunnel syndrome gingivitis bad breath infections shingles repeated sinus infections face pain teeth grinding neuritis teeth clenching night mouth guard neuralgia racing heart slow heart NUTRITION any of the above doctor diagnosed vegetarian vegan numbness tingling food restrictions pins / needles food allergies supplements WOMEN menstruation: painful heavy scant pregnant # of children miscarriage(s) menopause (date) bone density exam (date) fractures hormone therapy gynecological surgeries Touch Matters - Rev. 09/2013 2
3 SURGERY TYPES DATE INJURIES TYPES DATE MEDICATIONS NAME CONDITION BEING TREATED OTHER HEALTHCARE PRACTITIONERS Chiropractor Naturopath / Homeopath Physiotherapy Psychotherapy Spiritual Direction Acupuncture Other Touch Matters - Rev. 09/2013 3
4 LIFESTYLE QUESTIONS Please indicate which of the following you currently experience: Increased fatigued in the morning Feel overwhelmed in stressful situations Fully awake after the noon meal Feel better when on vacation Salt cravings Pain between shoulders, upper back and neck Decreased libido Often feel cold Experience muscle weakness Increase frequency of getting the flu Experience absent mindedness Increase frequency of getting respiratory Low energy between 2 4 pm infections Feel better after 6 pm Slower to recover from infections Work best late into the night Dry thin skin PMS, peri-menopausal, menopause symptoms worse when experiencing stress Need a coffee or other stimulant to get going in the morning How long have you experienced these symptoms? Please indicate which of the following you currently experience. You have noticed a decrease in your ability to concentrate. You often feel: depleted, unrested, exhausted, angry, teary, physically sore. ( circle all that apply to you ) You often wake up with a morning headache. You experience sleep apnea ( holding your breath at night while sleeping) You have been diagnosed with high blood pressure. You have trouble falling to sleep ( occasionally, frequently, always ) You fall asleep in less than 5 minutes You toss and turn during the night In the afternoon you feel tired, sleepy or have low energy You have asthma You notice that your legs are restless at night and may keep you awake or wake you up You have diabetes You have noticed or others have, that your job performance has gone down You snore at night when sleeping You struggle with weight gain You have been diagnosed with cardiovascular disease You use a sleep aid to fall to sleep: ( medication, herbals) You experience depression : (please indicate the medications used to manage this condition) You take stimulants (medications, coffee) to help you stay awake You feel hot or cold while you are trying to sleep You experience insomnia Touch Matters - Rev. 09/2013 4
5 You have noticed a lower tolerance for alcohol You take naps: ( rarely, occasionally, frequently) You notice that you experience sleepiness while driving your vehicle When travelling by car you often don t remember the journey You have noticed that your eye-hand co-ordination is getting worse How long have you been experiencing these symptoms? Women only complete this section Hot flashes Mood swings Urinary incontinence Heart Palpitations Cystic ovaries Vaginal dryness Heavy Menses Foggy thinking Weight gain Fibrocystic breasts Irritability Increased body/facial hair Thinning skin Uterine Fibroids Night sweats Acne Depressed mood Headaches Bone loss Aches and pains Elevated triglycerides Allergic conditions Sleep disturbances Depression Susceptibility to infections Infertility Nervousness Bone loss Chronic illness Evening fatigue Blood sugar imbalances Morning fatigue Anxiety Auto immune illness Aches and pains Anxiety Brittle nails Dry skin Cold hands and feet Headaches Fatigue Foggy thinking Weight gain Heart palpitations Low libido Inability to lose weight Constipation Thinning hair Menstrual irregularities Depression Feeling cold all the Elevated Cholesterol Infertility time Sleep disturbances How long have you been experiencing these symptoms? Touch Matters - Rev. 09/2013 5
6 Men only complete this section Burned out feeling Irritable Infertility problems Decreased urine flow Hot flashes Erectile dysfunctions Oily skin Apathy Decreased stamina Weight gain (waist) Prostate problems Sleep disturbances Decreased libido Decreased mental Decreased muscle mass Night sweats sharpness Insomnia Increased urinary urge decreased urine flow Morning fatigue Aches and pains Elevated triglycerides Anxiety Sleep disturbances Depression Infertility Bone loss Blood sugar Auto immune illness Lack of motivation Fibromyalgia Prostate problems Allergic conditions Weight gain (waist) Chronic illness Evening fatigue Stress Prone to infections Decreased erections Lack of motivation Low libido Depression Decreased erections Foggy thinking Infertility Sleep disturbances Constipation Fatigue Inability to lose weight Elevated cholesterol Cold body temp Headaches How long have you been experiencing these symptoms? What are your goals for treatment? Please carefully consider the physical pains, aches, lack of mobility and any other limitations that you would like to see change. By specifying each issue you would like to see change, makes the sessions more effective and productive in reaching your goals Touch Matters - Rev. 09/2013 6
7 Touch Matters - Rev. 09/2013 7
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