Patient Health History

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Transcription:

Patient Health History Today s Date / / Signature of Patient Patient Title: (check one) Mr. Mrs. Ms. Miss Dr. Prof. Rev. First Name Nick Name Last Name Middle Name Suffix Address 1 Address 2 City State Zip Code Primary Phone Secondary Phone Mobile Phone Home email Work Email By providing my email address, I authorize my doctor to contact me via the email address(es) provided. Which email address would you like us to use to communicate with you? (check one) Home Work Contact Method (check one) Primary Phone Secondary Phone Mobile Phone Home Email Work Email Date of Birth / / Age Gender (check one) Male Female Unspecified Marital Status (check one) Single Married Other SSN Employment Status (check one) Employed FT Student PT Student Other Retired Self Employed Race (check one) White Black/African American Hispanic American Indian/Alaskan Native Asian Asian Indian Chinese Filipino Japanese Korean Vietnamese Native Hawaiian or other Pacific Island Samoan Guamanian or Chamorro Other I choose not to specify Multi-Racial (check one) Yes No Unknown Ethnicity (check one) Hispanic or Latino Not Hispanic or Latino I choose not to specify Preferred Language (check one) English Spanish American Sign Language Chinese French German Tagalog Vietnamese Italian Korean Russian Polish Arabic Portuguese Japanese French Creole Greek Hindi Persian Urdu Gujarati Armenian I choose not to specify Continued Future Health 2011 1109-30

Verification Question (choose only one question by circling the question, then give the answer to that question) What is the name of your favorite pet? In what city were you born? What high school did you attend? What is your favorite movie? What is your mother s maiden name? On what street did you grow up? What was the make of your first car? When is your anniversary? Verification Answer to the Chosen question: Answers must be at least 6 characters. Do you currently smoke tobacco of any kind? Yes Former smoker Never been a smoker If yes, how often do you smoke: Current every day smoker Current sometimes smoker If yes, what is your level of interest in quitting smoking? 0 1 2 3 4 5 6 7 8 9 10 No interest Very Interested Current medications, including frequency and dosage if known. If there are no current medications, check here: Start Date 1) 5) 2) 6) 3) 7) 4) 8) Start Date List any known allergies you have had to any medications. If no allergies are known, check here: 1) 3) 2) 4) Briefly list your main health problems: Has any doctor diagnosed you with Hypertension presently? Yes No If yes, describe: Has any doctor diagnosed you with Diabetes presently? Yes No If yes, what kind? Type I Type II If yes to Diabetes, was your blood lab-work test for hemoglobin A1c > 9.0%? Yes No Not Sure If yes, other comments regarding Diabetes: Have you had an X-ray or CT scan or MRI of your low back spine in the past 28 days? Yes No To be performed by clinic staff: Height: inches Weight: pounds BP: / Future Health 2011 1109-30

Review of Systems Are you currently suffering from any of the symptoms listed below? General Fatigue Weakness Fever (continuous) Loss of Sleep Chills (continuous) Weight Change (unplanned) Night Sweats Headaches Dizziness Fainting Convulsions Nervousness Anxiety Depression (prolonged) Phobias (excessive fears) Memory Loss or Impairment Mood Swings (excessive) Hearing Trouble Ringing/Pain in Ears Vision Trouble Pain in Eyes Nose/Sinus Pain Excessive Drainage Nose Bleeds (chronic) Nasal Infections (chronic) Absence of Smell Mouth Sores Bleeding Gums Enlarged Glands Absence of Taste Abnormal Taste Sensation Tonsillitis/Infected Tonsils Difficulty with Swallowing Heat/Cold Intolerance Sugar in Urine Goiter (enlarged Thyroid gland) Tremor (shaking) Skin Rash Redness Of Skin Skin Itching Skin Dryness Eczema (red, inflamed skin) Hair Changes (unplanned) Nail Changes (unplanned) Bruise Easily Cough (chronic) Wheezing (chronic) Difficulty Breathing Swollen Extremities Blue Extremities Varicosities (visible veins) Rapid Heart Beat Chest Pain Heart Palpitations Heart Murmur Decreased Appetite Increased Appetite Abdominal Pain Hemorrhoids Excess Gas Vomiting (excessive) Diarrhea (excessive) Constipation (excessive) Heartburn/Indigestion Painful Urination Inability to Hold Urine Frequent Urination Urinary Retention Bed-wetting Irregular Menstruation Painful Menstruation Abnormal Vaginal Bleeding Sterility Impotence Lumps in Breast(s) Redness/Itching of Breast Dimpling of Breast(s) Breast Pain Discharge from Breast(s) Habits/Activities What are your current habits? (Circle One) Caffeinated Drink Never <1 glasses/day 2-3 3-4 5+ Alcohol consumption Never <1 glasses/day 2-3 3-4 5+ Drug/Substance Abuse No Yes Exercise Never <1 days/week 2-3 3-4 5+

Medical History (Please Answer) Have you Ever Been To a Chiropractor? Do You Have A Family Physician? Date of Last Physical Exam: Physicians Name: Have You Been Hospitalized In the Past? Date & Reason for Hospitalization: Have you Ever Had Surgery? Date, Reason, Results of Surgery: Have You Ever Had a Serious Accident/Injury? List Date & Describe Injury: Family History Please Check All that Apply Cancer Diabetes Heart Trouble High Blood Pressure Stroke Kidney Disease Anemia Mental Illness Headaches Osteoporosis Arthritis Joint Problems Scoliosis Back Problems Disc Problems Congenial Defects Genetic Disease Conditions or Illnesses Please Indicate if you Now Have with H or if you Had In the Past with P For Any of The Following Illnesses: _ Sinus Trouble _ Hay Fever _ Allergies _ Asthma _ Emphysema _ Tuberculosis _ History of Infection _ Fever (Continuous) _ Cancer/Tumor _ Diabetes _ Visual Disturbances _ Dizziness/Fainting _ Epilepsy/Seizures _ Thyroid Trouble _ High Blood Pressure _ Low Blood Pressure _ Heart Trouble _ Pacemaker _ Stroke (Date: ) _ Aortic Aneurysm _ Anemia _ Rheumatic Fever _ Polio _ Multiple Sclerosis _ Ulcer _ Liver Trouble _ Kidney Trouble _ Urinary Retention _ Prostate Trouble _ Arthritis _ Osteoporosis _ Scoliosis _ Dislocated Joints _ Spinal Disc Disease _ Bone Fracture (List/date ) _ Mental/Emotional Difficulty _ Sex. Trans. Disease _ HIV _ AIDS _ Abnormal Weight Gain _ Abnormal Weight Loss _ Numbness Groin/Buttocks

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