Please complete this questionnaire in its entirety, even if you feel some questions may not apply to you. Our staff is available should you have any questions, or need assistance with the completion of this form. Date of initial appointment: / / Appointment time: am/pm Birth place: Last First M.I. Maiden Birthdate: / / Address: Age: Sex: M F Telephone: H ( ) City State Zip W ( ) C ( ) Marital Status: Never Married Married Divorced Separated Widowed Spouse/Significant Other: Alive/Age Deceased/Age Major Illness Education (circle highest level attended): Grade School: 7 8 9 10 11 12 College Level: 1 2 3 4 Graduate School: Occupation: Number of hours worked/average per week: Referred here by (check one): Self Family Friend Doctor Other Health Professional Name of person making referral: Name of physician providing your primary medical care: Describe briefly your present symptoms or reasons for visit: Date symptoms began (approximate): Diagnosis: Previous treatment for this problem, including physical therapy, surgery and injections. (Medications to be listed later): Please list the names of other practitioners you have seen for this problem:
1. How many serious drug reactions have you had in your lifetime? (check one) 0 1 2 3 4 or more 2. Who is your most trusted source of medical advice? (check one) Family or Friends Chiropractor Physician/Nurse Practitioner Internet Other 3. Is medical care a financial burden for you? Yes No Systems Review (check mark if you have had any of these problems in the LAST MONTH): Y N Y N Y N Chest pain Hair loss Persistent diarrhea Constipation Headache Rash Cough Heartburn Ringing in ears Dark/bloody stool Heat intolerance Shortness of breath Difficulty swallowing Hoarseness Skin nodules Difficulty urination Joint swelling, redness or Stomach pain warmth Dizziness Loss of hearing Sun sensitivity Easy bruising Memory loss Swollen/tender glands Eye dryness Mouth dryness Unusual bleeding Eye pain Mouth sores Unusual fatigue Eye redness Nausea Weight gain (>10 lbs.) Feeling sickly Night sweats Weight loss (<10 lbs.) Fever Numbness/tingling White or blue fingers in cold Gyneco/prostate problems Palpitations If you are experiencing stiffness in your joints in the morning, approximately how long does the stiffness last? No stiffness 30 min or less >30 min-1 hour >1-2 hrs >2-4 hrs >4-8 hrs More than 8 hrs Menstrual (Women Only): Age when period began: Regular periods: Yes No How many days apart: Date of last period: 2
Please check yes or no to indicate whether you have any of the conditions listed below. Please indicate your age when the problems began. Y N Age Y N Age Blood clots Hypertension Cancer Kidney stone Celiac disease Nervous breakdown Colitis (other) Overactive thyroid Colitis (ulcerative) Parathyroid disorder Crohn s disease Primary biliary cirrhosis Depression Psoriasis Diabetes Sleep disorder Elevated cholesterol/lipid disorder Stomach reflux (GERD) Heart problems Stroke Hepatitis Underactive thyroid HIV 1. Have you ever been exposed to Hepatitis? Yes No Tuberculosis? Yes No 2. Date of last skin test for tuberculosis: 3. Have you had a low trauma fracture (occurring with fall from standing height, or less)? Yes No If yes, list bones fractured: 4. Did either parent have a low trauma hip fracture? Yes No 5. How many falls have you had in the last 12 months? Previous Operations: 1 2 3 4 5 6 7 TYPE of OPERATION YEAR REASON 3
Social History: 1. Do you drink caffeinated beverages? Yes No Cups/glasses per day? 2. Do you smoke? Yes No Past How long ago? 3. Do you drink alcohol? Yes No Number per day: 4. Do you exercise regularly? Yes No Type: Times per week: 5. How many hours of sleep do you get at night? 6. Do you get enough sleep at night? Yes No Do you wake up feeling rested? Yes No 7. Are you receiving disability? Yes No Are you applying for disability? Yes No Family History: Father IF LIVING IF DECEASED Age Health Age at Death Cause Mother Number of siblings: Number living: Number deceased: Number of children: Number living: Number deceased: List age(s) of each child(ren): Health of children: Do you know of any blood relative who has, or had, any of the following (check and provide relationship): Blood clot disorder Lupus (SLE) Cancer Osteoarthritis Colitis Osteoporosis Depression Psoriasis Diabetes Psoriatic arthritis Gout Rheumatoid arthritis Heart disease Thyroid disorder High blood pressure Tuberculosis 4
Medications: Please provide a list of current medications for the date of your appointment. DRUG ALLERGIES: No Yes List: Type of reaction: Present: (List all medications that you are taking at this time. Include such items as aspirin, calcium, laxatives, supplements, vitamins, etc.) 1 Name of Drug Strength Dosage How long have you taken this medication Please Check: Helped? A Lot Some Not at All 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 5
Prior Medications: Please check all medications previously taken. For Osteoporosis/Osteopenia Actonel (risedronate) Fosamax (Alendronate) Boniva (ibandronate) Boniva IV Didronel (etidronate) Forteo (teriparatide) Miacalcin (calcitonin) Prescription strength Vitamin D Reclast IV For Rheumatoid/Inflammatory Arthritis Actemra Imuran (Azothiaprine) Prednisone Cimzia Leflunomide Remicade (infliximab) Cytoxan (cyclophosphamide) Methotrexate Rituxan Enbrel (etanercept) Orencia Simponi Gold Otezla Sulfasalazine Humira Plaquenil (hydroxychloroquine) Xeljanz For Gout Allopurinol Probenecid Colchicine Uloric For Painful Conditions Arthrotec Naprosyn, Naproxen, Aleve Aspirin Celebrex Clinoril (sulindac) Cymbalta Daypro (oxaprozin) Hydrocodone Lodine (etodolac) Lyrica Mobic (meloxicam) Morphine Motrin (ibuprofen), Advil Neurontin (gabapentin) Oxycodone/Oxycontin Percocet Piroxicam Relafen (nabumetone) Savella Tramadol Vicodin Voltaren (diclofenac) Other 6
IF YOU ARE BEING EVALUATED FOR A PAINFUL CONDITION, please complete this page (Page 7). 1. How much of a problem has UNUSUAL fatigue or tiredness been for you OVER THE PAST WEEK? No Problem 1 2 3 4 5 6 7 8 9 10 Major Problem 2. How much of a problem has sleeping been for you OVER THE PAST WEEK? No Problem 1 2 3 4 5 6 7 8 9 10 Major Problem 3. How much pain have you had because of your condition OVER THE PAST WEEK? Please indicate below how severe your pain has been: No Pain 1 2 3 4 5 6 7 8 9 10 Terrible Pain 7
4. Please place a check in the appropriate box to indicate the amount of pain you are having in each of the joint areas listed below: Indicate on a scale of 0 to 3: 0: None 1: Mild 2: Moderate 3: Severe Left fingers 0 1 2 3 Right fingers 0 12 3 Left wrist 0 1 2 3 Right wrist 0 12 3 Left elbow 0 1 2 3 Right elbow 0 12 3 Left shoulder 0 1 2 3 Right shoulder 0 12 3 Left hip 0 1 2 3 Right hip 0 12 3 Left knee 0 1 2 3 Right knee 0 12 3 Left ankle 0 1 2 3 Right ankle 0 12 3 Left toes 0 1 2 3 Right toes 0 12 3 Neck 0 1 2 3 Back 0 12 3 5. Considering all the ways in which illness and health conditions may affect you at this time, please indicate below how you are doing: Very Well 1 2 3 4 5 6 7 8 9 10 Very Poorly 8