HEALTH HISTORY QUESTIONNAIRE

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Transcription:

1525 S. Alafaya Trail Unit 105 / Orlando, FL 32828 T: 407-282-4449 F: 407-282-4438 www.synhealthcare.com HEALTH HISTORY QUESTIONNAIRE Name: Date: Address: City: State: Zip: S.S. #: Cell Phone: Home Phone: Work Phone: Email: Age: Date of Birth: Gender: F M Marital Status: Single Married Divorced: Widowed: Primary Care Physician: Business/Employer: Type of Work: Height: Weight: Have you been to a chiropractor before? Yes No How did you hear about/find us? Problem Date of Onset Severity(Scale 0-10) Treatment Tried Success Example: Neck Pain May 2014 5/10 Acupuncture/Advil Mild Improvement What diagnosis or explanation, if any, has been given to you for these concerns? What makes your symptoms worse? What makes you feel better?

MEDICATIONS List all medications you are currently on. Include all over the counter non-prescription drugs. Name Date Started Date Stopped Dosage/Frequency List all vitamins, minerals and any nutritional supplements that you are taking now. Name Date Started Date Stopped Dosage/Frequency PAST MEDICAL AND SURGICAL HISTORY If you have experienced a reoccurrence of an illness, please indicate when or how often under the comments. ILLNESS WHEN/ONSET COMMENTS Arthritis Asthma Cancer Diabetes Epilepsy, Convulsions, Seizures Heart Attack, Angina Heart Failure High Blood Pressure Stroke Thyroid Disease

INJURIES WHEN COMMENTS Neck/Back Injury Broken Bones Head Injury Car Accidents Other (Describe) DIAGNOSTIC STUDIES WHEN COMMENTS Bone Density Test CAT/CT Scan (please indicate region) EMG/NCV MRI (please indicate region) X-rays (please indicate region) SUGERIES WHEN COMMENTS Neck or Back Other (Describe) FAMILY HISTORY WHO COMMENTS Heart Disease Cancer Diabetes Autoimmune Disease Mental Illness HOSPITALIZATIONS WHERE HOSPITALIZED WHEN REASON

REVIEW OF SYMPTOMS Check ( ) those items that applied to you in the past. Circle those that presently apply. GENERAL: Fever Difficulty falling asleep Swollen Glands Fatigue NECK: Stiffness Swelling Lumps SKIN: Rashes Psoriasis Bruise easily Changing Moles Skin cancer Shingles NOSE/SINUSES: Infection No sense of smell MOUTH: TMJ Issues Fever blisters THROAT: Difficulty swallowing Frequent hoarseness Enlarged glands GASTROINTESTINAL: Indigestion Heartburn Gallstones Abdominal Pains/Cramps Acid Reflux Rectal Bleeding Bloody stools Ulcers Diarrhea HEAD: Poor Concentration Headaches: Severe Migraine Occipital Frontal Forgetfulness EYES: Visual hallucinations Eye pains Floaters in eyes Blurred vision Cataracts EARS: Aches Ringing Deafness/Hearing loss Frequent infections CIRCULATION/RESPIRATION: High Blood Pressure Chest pain Shortness of breath Irregular Heart Beat High Cholesterol Emphysema Dizziness upon standing Palpitations Night sweats Murmurs Heart Enlargement Prior Heart Attack? / / KIDNEY/URINARY TRACT: Blood in urine Problem passing urine Night time urination Painful/Burning urination Kidney stones/infections Loss of bladder control Urgency/Hesitancy/Change in Urinary Stream

MEN S HISTORY (for men only): Prostate cancer Have you had a PSA done? Yes No Prostate enlargement Genital Pain Hernia WOMEN S HISTORY (for women only): Endometriosis Non-period bleeding Lumps in breasts Partial/Total Hysterectomy Breast Cancer Ovarian Cysts Pregnant Fibroid tumors/uterus Heavy Bleeding LIFESTYLE HISTORY TOBACCO HISTORY Have you ever used tobacco? Yes No How much? Number of years? If not a current user, year quit? ALCOHOL INTAKE How often do you consume alcohol? 0-5 drinks per week >5 drinks per week EXERCISE HISTORY Do you exercise regularly? Yes No If yes, please indicate: Times/week Length of Session Type of Exercise Jogging/Walking Aerobics Strength Training Pilates/Yoga/Tai Chi Sports (tennis, golf, soccer, basketball) Other (please indicate) 1x 2x 3x 4x+ <15 15-30 30-45 >45 I declare under penalty of perjury (under the laws of the United States of America) that the foregoing is true and correct: I am not attempting to investigate Synergy Healthcare as a representative of any agent or entity, or any insurance company or other organizational entity or person. Name: Date: Signature:

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