Confidential Patient History Form - Noble Choice Chiropractic
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1
2CONFIDENTIAL PATIENT HISTORY
2410 Montana Ave
Sun Prairie, WI 53590
p. (608) 3185300
f. (608) 3185353
Patient _______________________________________________ Date: _________________ Height: ______________
Weight: _______________ Referred by: ________________________________________________________________
Major complaint and symptoms: _______________________________________________________________________
How do you believe your problem (pain) began? __________________________________________________________
When did you first notice this problem/pain?______________________________________________________________
Which positions or activities aggravate your condition? ______________________________________________________
Which positions or activities relieve your condition? ________________________________________________________
Have you ever been treated by any other physicians for this ailment? Yes / No
If yes, where? _____________________________________________________________________________________
Diagnosis of previous physician _______________________________________________________________________
Length of time under care _____________________ Results ________________________________________________
General Health Questionnaire
Do you have vertigo (dizziness)?........................................................................................................................Yes / No
Do you pass out easily (faint or loss of consciousness)? ..................................................................................Yes / No
Do you have double vision or have you lost sight in one eye? ...........................................................................Yes / No
Do you have any slurred speech or difficulty with speech? ...............................................................................Yes / No
Do you have indigestion or difficulty swallowing? ..............................................................................................Yes / No
Do you have any difficulty walking, with coordination or falling to one side? .....................................................Yes / No
Do you have nausea or vomiting? ......................................................................................................................Yes / No
Do you have numbness on one side of your face or body? ...............................................................................Yes / No
Do you have any visual disturbances or rapid eye movement? .........................................................................Yes / No
Do you have or have you ever had difficulty in arranging words properly? ........................................................Yes / No
Do you have a headache or head pain that is unlike any you have had before? ...............................................Yes / No
Do you have headaches for hours or days? .......................................................................................................Yes / No
Do you have a history of stroke in your family? ..................................................................................................Yes / No
Do you have chest pain? ....................................................................................................................................Yes / No
Do you have a sore that does not heal? .............................................................................................................Yes / No
Do you have any unusual bleeding or discharge? ..............................................................................................Yes / No
Do you have a nagging cough or hoarseness? ...................................................................................................Yes / No
Do you have night sweats? ..................................................................................................................................Yes / No
Do you have pain in the neck, jaw or face? ..........................................................................................................Yes / No
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