Patient Name: Address City State Zip Code. H. Phone W. Phone Cell Phone. Do you want statements ed? Y/N

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Transcription:

Address City State Zip Code H. Phone W. Phone Cell Phone Would you like text apt. Reminders? Y/N If yes Cell Carrier Email address Do you want statements emailed? Y/N Sex M F Marital Status M S D W Emergency Contact / # Date of Birth Age Social Security # Occupation Employer Referred by: Have you ever received Chiropractic Care? Yes No If yes, when? Name of most recent Chiropractor: 1. Reasons for seeking chiropractic care: Primary reason: Secondary reason: 2. Previous interventions, treatments, medications, surgery, or care you ve sought for your complaint(s): 3. Past Health History: A. Please indicate if you have a history of any of the following: Anticoagulant use Heart problems/high blood pressure/chest pain Bleeding problems Lung problems/shortness of breath Cancer Diabetes Psychiatric disorders Bipolar disorder Major depression Schizophrenia Stroke/TIA s Other None of the above B. Previous Injury or Trauma: 1

Have you ever broken any bones? Which? C. Allergies: D. Medications: Medication Reason for taking E. Surgeries: Date Type of Surgery 4. Family Health History: Do you have a family history of? (Please indicate all that apply) Cancer Strokes/TIA s Headaches Cardiac disease Neurological diseases Adopted/Unknown Cardiac disease below age 40 Psychiatric disease Diabetes Other None of the above Social and Occupational History: A. Job description: B. Work schedule: C. Recreational activities: D. Lifestyle (hobbies, level of exercise, alcohol, tobacco and drug use, diet): 2

Review of Systems Have you had any of the following pulmonary (lung-related) issues? Asthma/difficulty breathing COPD Emphysema Other None of the above Have you had any of the following cardiovascular (heart-related) issues or procedures? Heart surgeries Congestive heart failure Murmurs or valvular disease Heart attacks/mis Heart disease/problems Hypertension Pacemaker Angina/chest pain Irregular heartbeat Other None of the above Have you had any of the following neurological (nerve-related) issues? Visual changes/loss of vision One-sided weakness of face or body History of seizures One-sided decreased feeling in the face or body Headaches Memory loss Tremors Vertigo Loss of sense of smell Strokes/TIAs Other None of the above Have you had any of the following endocrine (glandular/hormonal) related issues or procedures? Thyroid disease Hormone replacement therapy Injectable steroid replacements Diabetes Other None of the above Have you had any of the following renal (kidney-related) issues or procedures? Renal calculi/stones Hematuria (blood in the urine) Incontinence (can t control) Bladder Infections Difficulty urinating Kidney disease Dialysis Other None of the above Have you had any of the following gastroenterological (stomach-related) issues? Nausea Difficulty swallowing Ulcerative disease Frequent abdominal pain Hiatal hernia Constipation Pancreatic disease Irritable bowel/colitis Hepatitis or liver disease Bloody or black tarry stools Vomiting blood Bowel incontinence Gastroesophageal reflux/heartburn Other None of the above Have you had any of the following hematological (blood-related) issues? Anemia Regular anti-inflammatory use (Motrin/Ibuprofen/Naproxen/Naprosyn/Aleve) HIV positive Abnormal bleeding/bruising Sickle-cell anemia Enlarged lymph nodes Hemophilia Hypercoagulation or deep venous thrombosis/history of blood clots Anticoagulant therapy Regular aspirin use Other None of the above Have you had any of the following dermatological (skin-related) issues? Significant burns Significant rashes Skin grafts Psoriatic disorders Other None of the above Have you had any of the following musculoskeletal (bone/muscle-related) issues? Rheumatoid arthritis Gout Osteoarthritis Broken bones Spinal fracture Spinal surgery Joint surgery Arthritis (unknown type) Scoliosis Metal implants Other None of the above Have you had any of the following psychological issues? Psychiatric diagnosis Depression Suicidal ideations Bipolar disorder Homicidal ideations Schizophrenia Psychiatric hospitalizations Other None of the above Is there anything else in your past medical history that you feel is important to your care here? I have read the above information and certify it to be true and correct to the best of my knowledge, and hereby authorize this office of Chiropractic to provide me with chiropractic care, in accordance with this state's statutes. If my insurance will be billed, I authorize payment of medical benefits to /Huffman Chiropractic, PLLC for services performed. Patient or Guardian Signature Date 3

NEW PATIENT HISTORY FORM Please start at the top of your body and work your way down, i.e. Headache, Neck Pain, etc. Symptom 1 Other Symptom 2 Other 4

Symptom 3 Other Symptom 4 waist, tilting right at waist, sitting, standing, getting up from sitting position, lifting, any movement, driving, walking, running, nothing, other (please Other 5

Symptom 5 Other Symptom 6 waist, tilting right at waist, sitting, standing, getting up from sitting position, lifting, any movement, driving, walking, running, nothing, other (please Other 6

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