PATIENT HISTORY FORM
Name: Date: _____
Address:___________________________________City:__________________State:________Zip:_______
Home Phone:_____/_____/_______ Work:_____/_____/_______ ext:_______ Cell:_____/_____/_______
E-Mail address (for emergencies and newsletters only)___________________________________________
Date of Birth:________/________/_______Age:____________Height: __ft. __in. Weight: _____
Marital Status: M S W D Name of Spouse: ______________________________________________
Children? Y N Names/Ages of Children: _____
Employer: ____________Occupation:_______________________________
Emergency Contact Person: Relation:____________________________ Address: ________City:______________State:__________Zip:________ Phone:_______/_______/_______ Who referred you here? ___________________________________
COMPLAINTS/HEALTH PROBLEMS
o I am here for a general health evaluation. o I am suffering from a particular health problem.
Please describe your complaints, including when and how they started:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
What treatments and tests have you received for your problems so far? __________________________________________________________________________________________
Have you seen other chiropractors? Y N Name:_____________________________________________
Location:______________Reason/diagnosis: __________________________________________________
List past surgeries and dates:_______________________________________________________________ _________________________________________________________________________________________
Who is your primary physician? Name: __________________________________ Location: ____________
When was your last physician visit? Date:____________Reason:__________________________________
Do you smoke now? Y N Have you ever smoked? Y N
If yes, how long, how much, and when did you quit? ______________________________________________
Please list previous accidents/injuries, including major childhood traumas with dates and hospitalizations:
____________________________________________________________________________________________________________________________________________________________________________________
List vitamins/supplements you take: _____________________________________________________
________________________________________________________________________________
List any over the counter or prescription medication:_____________________________________________
______________________________________________________________________________________
Explain your job requirements-positions/postures: ________________________________________________
What childhood illnesses have you had (measles, chicken pox, etc.)? __Usual Other: _______________
What are your problems preventing you from doing? Sports _____________ Hobbies _______________
Family/Kids ____________________ Work ____________________ Other ____________________
Check any of the following conditions you have had or do have:
__ Allergies __ Eczema __ Neck Pain
__ Sinus Problems __ Other Skin Problems __ Mid Back Pain
__ Asthma __ Headaches __ Low Back Pain
__ Anemia __ Migraines __ Shoulder Pain L R
__ Arthritis __ Heart Disease __ Elbow Pain L R
__ Cancer __ Heart Attack __ Hand Pain L R
__ Depression __ Menstrual Problems __ Hip Pain L R
__ Diabetes __ Multiple Sclerosis __ Leg Pain L R
__ Digestive Problems __ Stroke __ Knee Pain L R
__ Drug Abuse/Addiction __ Weight Problems __ Foot Pain L R
__ Alcoholism __ Ringing in Ears __ Carpal Tunnel L R
__ Stress __ Dizzy/Balance Problems __ (Other)___________________
o Yes oNo Any personality/emotional changes? If so, what? ___________________________________
o Yes oNo Any changes to your sense of smell?
o Yes oNo Do you see spots or any disturbances to your vision?
oYes oNo Do your eyes and/or mouth get dry?
o Yes oNo Does your heart feel like it races?
o Yes oNo Do you break a sweat easy?
o Yes oNo Do you sweat more on one side of the body than the other?
o Yes oNo Have you noticed any changes in your bowel or bladder function? If so, what?____________
___________________________________________________________________________
o Yes oNo Any changes in sexual function? If so, what?_______________________________________
o Yes oNo Have you noticed any short or long-term memory changes?
o Yes oNo Any changes in your energy level; fatigue?
o Yes oNo Do you have any muscle twitches?
o Yes oNo Do you exercise regularly? If so, what kind of exercise?______________________________
____________________________________________________________________________
o Yes oNo Do you consume caffeine (coffee, soda, tea)? If so, how much? _______________________
o Yes oNo Do you choke on foods or liquids?
o Yes oNo What did you eat and drink yesterday?____________________________________________
How old are your parents and what is their state of health? _______________________________________
If deceased, cause of death: ______________________________________________________________
Siblings, ages, and health: _________________________________________________________________
By my signature below, I certify that the above information is correct. I authorize Fuller Chiropractic, P.C. to perform an examination, take x-rays if necessary, and administer chiropractic treatment. I authorize Fuller Chiropractic to contact other health care providers I have to coordinate my care, and to release information to my other providers for coordination of care, and to release my health information for insurance reimbursement purposes.
_____________________________________ _______/_______/_______
Patient Signature Date
|
