Patient History (Please Print)

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Transcription:

Patient History (Please Print) Date: Name: Email: Phone: (Home) (Mobile) (Work) Address: City: Zip: Birth Date: / / Male Female Spouse/Parent Name: # of Children: Married Single Divorced Widowed Are you Pregnant? YES NO Due Date: Occupation: How were you referred to our office? If from the internet, name of search engine and key words used: Have you ever had Chiropractic Care before? If yes, when? Is this injury related to a work injury or automobile accident? Yes No Have you reported the injury to your employer? Yes No PLEASE NOTIFY THE FRONT OFFICE TEAM TO LET THEM KNOW YOU WERE INJURED AT WORK OR AUTOMOBILE ACCIDENT. Do you have any health insurance? Yes No Name of PCP Phone PLEASE GIVE YOUR HEALTH INSURANCE CARD TO THE FRONT OFFICE TEAM IF YOU HAVE HEALTH INSURANCE List your chief complaints in order of severity; Check all those that describe your condition: Complaint 1: For How Long? Complaint 2: For How Long? \\Server\mo\ATLAS\New Patient Forms\General New Patient forms Revised 8.1.18

Complaint 3: For How Long? Mark an X on the areas you feel pain. Draw an arrow if the pain travels. Include all affected areas. Does your condition interfere with you: Work NO Causes slight increase in pain Have to alter job duties Can t work Daily Routine NO Causes Increase in pain Need help due to increase in pain Recreation NO Causes Increase in pain Have to change workout Can t do If your condition interferes with the following please answer, Pain prevents me from: Sitting more than >1hr 1/2hr 10min I avoid sitting Standing: I can t stand longer than 1 hour 1/2 hr 10min I avoid standing Walking: I can t walk longer than 1mile 1/2mile 1/4mile I avoid walking Sleep disturbed <1hr sleepless 1-2hr sleepless 2-3hr sleepless >3hrs sleepless List any other activities you are unable to perform:

Does your condition interfere with any of the following: Computer Use Sports Reading Exercise Vacuuming Social Life Cleaning Cooking Watching Kids Yard Work Driving Relationship Shopping Gardening School Self Care Other: Family History (please list all known conditions/illnesses that may apply): Mother: Father: Grandparents: Siblings: Other known familial conditions: Social History: Smoking Do not smoke Smoke 1 pack or less per day Smoke more than 1 pack per day Alcohol I don t drink alcohol Drink alcohol occasionally Drink alcohol often Exercise I don t exercise Exercise occasionally Exercise often Stress Experience stress occasionally Experience stress often List of Current Medications/Supplements: List of Previous Hospital Stays/Surgeries: List of Any Childhood Traumas / Past Accidents / Falls / Auto Injuries: Is there anything else you think we should know about or that you would like to discuss? (Explain): Are you interested in Nutritional Services? (i.e, Nutritional Consultation, Hair Mineral Analysis, or Nutrient Analysis) YES NO

REVIEW OF SYSTEMS GENERAL CONSTITUITIONAL Fatigue Fever Weakness Weight Loss Anxiety Depression Cancer Type BlOOD/LYMPH Bruising BREASTS Lumps Pain Discharge EARS, NOSE, THROAT, AND MOUTH Hearing Loss Earache Discharge Ringing Soreness Swallowing Infection Hoarseness Bleeding Loss of Smell Obstruction Sinus Problems Bad Breath Bleeding Gums Ulcers Dental Problems Loss of Taste EYES, VISION Blurry Double Pain Floaters GASTROINTESTINAL Abdominal Pain Nausea Vomiting Diarrhea Constipation Bloody Stool Black Stool Jaundice Heartburn Hemorrhoids Belching Loss of Appetite GENITOURINARY Urinary Hesitancy Incontinence Urgency Frequency Painful Urination Kidney Stones Kidney Failure Dialysis HEAD Headaches Injuries Dizziness HEART, CARDIOVASCULAR Chest Pain Cold extremity Ankle Edema Murmur Varicosity Blood Clots Palpitations Abnormal Heart Rhythm MAN Impotence Loss of Libido Dribbling

REVIEW OF SYSTEMS MUSCULOSKELETAL Joint Pain or Swelling Restricted Range of Motion Musculoskeletal Pain Arthritis Type NEUROLOGICAL Numbness or tingling sensation Sensation Loss Burning RESPIRATORY Shortness of breath Cough Wheezing SKIN AND INTEGUMENTARY Rashes Itching Dryness Mole Changes Sores Painful Sex WOMAN Painful Sex Discharge Irreg Periods Hot Flashes Loss of Libido Went over with the patient Doctor s Signature Notice: Not all patients require x-rays to determine or verify a diagnosis, type and length of care. If your examination warrants x-ray analysis, the following office policy prevails: 1. All first visit charges are to be paid when services are rendered. The fee paid for x-rays is for analysis only. The film itself is the property of this office and cannot be released. *** If you have insurance please give the front desk your card ***

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