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Transcription:

CHIROPRACTIC INTAKE FORM A Multidisciplinary approach to medicine is holistic and seeks to understand all factors that may be affecting your health. Please answer the following questions to the best of your ability. Name: Date: Date of Birth: (m/d/y) Age: Sex: Male / Female Mailing Address: City: Postal Code: Email: Telephone May we leave a message? Home/Eve: ( ) _ Work/Day: ( ) _ Cell: ( ) _ What is the best way to contact you? HOME / WORK / CELL I give my consent to include my e-mail address on the clinic newsletter mailing list How did you hear about The Natural Way/ who may we thank? Google Website Preferred Card Talk Website Total Woman Show Newsletter Student Care Network Yellow Pages Patient Referral: The Natural Way Staff: External Practitioner: Other: Occupation Ethnic Background Marital Status DO YOU HAVE DIFFICULTY CLIMBING STAIRS? EMERGENCY CONTACT Name: Phone: Relation: PREVIOUS CARE Have you seen a Naturopathic Doctor before? If yes, was it a positive experience? Please explain: Have you had chiropractic treatment before? If yes, was it a positive experience? Please explain: Are you interested in preventative maintenance care? YES/ NO Is your current condition the result of a motor-vehicle accident?

Is your current condition the result of a work-related injury? For women: Is it possible that you are currently pregnant? YES/NO CHIEF COMPLAINT What are your health concerns? (Please list in order of importance): 1. 2. 3. 4. HEALTH PROFESSIONALS Please list health professionals from which you currently receive care (ex. Medical Doctor, Specialists, Physiotherapist, Massage Therapist, Naturopathic Doctor, and Chiropractor). In addition, please circle YES or NO, beside each practitioner, indicating your permission for us to contact each practitioner, as necessary, regarding your case. Permission for Exchange of Information 1. Name: Address: Phone: Fax: Type of Practitioner: 2. Name: Address: Phone: Fax: Type of Practitioner: What other types of treatment or health-care practitioners have you consulted for treatment of these health issues? List any lab work, x-rays, or consultations with specialists related to your condition (include dates): Please provide information regarding the following health tests, if applicable: Test Date Normal Abnormal Blood Pressure Bone Density MRI/CT Scan Nerve Conduction Studies MEDICATIONS List any prescribed medications you are currently taking along with doses and the date this medication was started: Name of Medication: Date started: Dose:

List any over-the-counter medications, dietary supplements, or herbs you are currently taking: Name: Date started: Dose: Please List Any Drug, Food, or Environmental Allergies: Please circle (o) any condition/symptom currently causing you problems. Please underline conditions/symptoms that were a problem in the past: GENERAL SYMPTOMS Loss of consciousness Blackouts Headache Fever Sweats Fainting Dizziness Clumsiness Convulsions Loss of sleep Numbness Pain Tingling Nervousness Weight loss Eating disorder Anemia EMOTIONAL Depression Anxiety Mood swings/irritability Phobia Alcohol/Drug Abuse MALE REPRODUCTIVE Testicular mass Prostate trouble Hernia FEMALE REPRODUCTIVE Painful menstruation Excessive flow Hot flashes Cramps/backache Vaginal discharge/itching Yeast infections Ovarian cysts/pcos Endometriosis Fibroids Swollen breasts Lumps in breasts Nipple discharge GASTROINTESTINAL Bloating Poor appetite Indigestion Heart burn/acid reflux Excessive hunger Belching or gas Bad breath Nausea Vomiting blood Abdominal pain/cramps over stomach Constipation Diarrhea Hemorrhoids Gall bladder trouble Ulcer Diabetes CARDIOVASCULAR High cholesterol High blood pressure Low blood pressure Bleeding disorder Pain over heart Stroke Varicose veins Swelling of ankles Poor circulation Heart or blood disease Angina Palpitations E.E.N.T Blurred vision Impaired vision Double vision Eye redness Eye pain Eye itching Eye discharge Eye dryness Floaters Deafness Earache Ringing/buzzing in ears Ear discharge Wax build-up Frequent ear infections Allergies Sleep apnea Post nasal drip Loss of smell Nasal polyps Frequent colds Frequent sore throats Sinus infection Enlarged glands/nodes Enlarged thyroid Speech problems Difficulty swallowing Cavities Gum problems MUSCLES & JOINTS Stiff neck Back ache Swollen joints Foot trouble Shoulder pain Arm/forearm pain Elbow pain Wrist pain Hand pain Arthritis Weakness RESPIRATORY Asthma Chronic cough Spitting up phlegm Spitting up blood Chest pain Difficulty breathing SKIN Rashes Itching Dryness Eczema Psoriasis Hives Boils Dryness Lumps Hair loss Nail change

PAST MEDICAL AND HEALTH HISTORY Please list any past serious injuries or illnesses, including when they occurred and any complications that you may have experienced: Please list any hospitalizations or operations, including why, when they occurred and any complications that you may have experienced: Have you ever experienced, or are you currently experiencing any of the following: Night sweats Significant or unexplained weight changes Pain that awakes you from sleep Date of last physical exam: FAMILY HEALTH HISTORY Please indicate if any family members (parents, siblings, grandparents), have had or have the following conditions: Diabetes Allergies Heart Disease Arthritis High Blood Pressure Autoimmune disease High Cholesterol Osteoporosis Stroke Depression Cancer Schizophrenia Seizures Alcohol/Drug abuse Kidney Disease Other Mental Illness Thyroid Dysfunction Other Asthma ACTIVITY/EXERCISE How active are you? Very Moderately Sedentary Do you have any physical problems that limit your activity? Yes / NO If yes, please describe: If you are not yet engaged in a routine exercise program, are you interested in starting? SLEEP/REST Number of hours of sleep per night? LIFESTYLE *Do you currently smoke cigarettes? Do you use any form of Recreation drug? If yes, please indicate which drug and how often: Do you drink alcoholic beverages? If yes, please estimate how much: wine (glasses/wk); beer (glasses/wk); liquor (glasses/wk) Do you drink caffeinated beverages? If yes, please indicate the equivalent number of regular sized cups per day: coffee (cup/day); tea (cup/day); cola (glasses/day)

Is there anything else that you would like to mention that has not been covered or feel it is important for me to be aware of? By signing this form, I certify that all of the information provided herein is complete and accurate to the best of my knowledge. If there are any changes to this information I will notify The Natural Way Health Clinic in a timely manner. I give permission to be contacted by The Natural Way Health Clinic as indicated in this form and for messages to be left at the indicated numbers. I give permission for an exchange of medical information to occur with those practitioners indicated within this form. I give permission for exchange of medical information to occur with other practitioners of The Natural Way Health Clinic, as needed for the purpose of consultation. Please list exceptions: Name of Patient or Guardian: Signature: Date: License# : Signature: Date:

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