Primary Chief Complaint 1. Location 2. When did this begin? 3. How did this begin?

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Transcription:

Name Date These questions that you are about to answer are very important for the Doctor. They will enable the doctor make a complete and diagnosis, and provide medical documentation (if needed)to your insurance company. What are your reasons for seeking chiropractic care? 1. 2. 3. If you only have 1 area of complaint then stop at primary, if you have more than one complaint then continue. Primary Chief Complaint 1. Location Does this complaint/pain radiate or travel to other areas of the body? N How frequent is the complaint/pain (circle all that apply)? Daily Weekly Monthly Other 1

Secondary Chief Complaint 1. Location Does this complaint/pain radiate or travel to other areas of the body? N How frequent is the complaint/pain (circle all that apply)? Daily Weekly Monthly Other Tertiary Chief Complaint 1. Location Does this complaint/pain radiate or travel to other areas of the body? N 2

How frequent is the complaint/pain (circle all that apply)? Daily Weekly Monthly Other Past Health History Previous Illness When Type Previous Trauma/Injury Have you had any broken bones? When Where Allergies Current Medications/ with dosage (Bring list is needed) Surgeries Date Type Females Have you had any pregnancies? How many? Vaginal or C Section Complications? Family Health History (circle all that apply) Mother Side Father Side Heart Disease Diabetes Heart Disease Diabetes Cancer Arthritis Cancer Arthritis Autoimmune Disorders Autoimmune Disorders Other 3

Social Occupation Job Description Recreational Activities What are your current primary sources of stress? What do you do in order to manage stress and take care of yourself? What is your exercise routine? Diet; please describe a typical day s diet for you. Don t forget beverages. Breakfast Lunch Dinner Snacks (what hour) Tobacco use: Y or N and if yes how much? Caffeine consumption: Y or N and if yes how much? How often? Alcohol consumption: Y or No and if yes how much? How often? Height : Weight: Review of Systems Circle any conditions that you may have had General malaise, fever, night sweats, chills, weight gain or loss Eyes: loss of vision, double vision, cataracts Ears: hearing loss, ringing in your ears, dizziness Nose: sinus infections, frequent bloody nose Throat: frequent sore throat, strictures, hoarseness Heart: chest pain, irregular heart beat, heart attacks, swelling of the legs or feet Lung: difficulty of breathing, shortness of breath, pneumonia, bronchitis, asthma, coughing up blood, tuberculosis Gastrointestinal: heartburn, stomach pain, blood in bowel movements, vomiting blood, ulcers, inability to control bowel movements Genitourinary: blood in the urine, burning when urinating, sexually transmitted diseases, discharge, inability to control urination 4

Gynecologic: female problems, uterus removed, ovaries removed, currently taking birth control pills or estrogen, heavy or irregular mense, pain on intercourse, pain during menstrual cycle Back: ruptured disc, car accidents, chronic pain, fractures, strains Neck: ruptured disc, car accidents, chronic pain, fractures, strains Musculoskeletal: muscle or bone diseases, broken bones, dislocations, osteoporosis, joint instability, chronic pain of an extremity Neurologic: loss of sensation, abnormal sensation, tingling, numbness, loss of motor function, decreased strength Skin: skin color changes, loss of pigmentation, abnormal moles, bleeding from moles, moles or dark spots increasing in size Psychiatric: nervous breakdowns, seeing or hearing things that aren t there, depression, abnormal behavior, taking medication for a psychiatric condition I have the read the above information and certify it to be true, and correct to the best of my knowledge. I authorize Life Line Chiropractic to provide my consultation to determine my eligibility to receive treatment within this office. By signing your name below you certify the accuracy of your medical and/or accident history and further certify that you present to Life Line Chiropractic for evaluation and/or treatment of a health condition and for no other purposes. Signature Date 5

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