Confidential Patient History Form - Noble Choice Chiropractic (Page 2 of 2) in pdf

Do you have a drooping eyelid or change in your pupils? ...................................................................................Yes / No

Do you have any ringing in your ears? ................................................................................................................Yes / No

Have you ever had cancer? .................................................................................................................................Yes / No

Does your pain ever wake you from a sound sleep? ...........................................................................................Yes / No

Are you losing any weight now without trying? ....................................................................................................Yes / No

Have you had any loss of bladder or bowel control? ...........................................................................................Yes / No

Have you lost consciousness or had double vision recently? ..............................................................................Yes / No

Do you take birth control pills? .............................................................................................................................Yes / No

Are you taking any prescription medications? ......................................................................................................Yes / No

If yes, please list ____________________________________________________________________________

Are you taking herbs, supplements, botanicals, or vitamins? ..............................................................................Yes / No

If yes, please list ____________________________________________________________________________

Are you taking any medication or overthecounter drugs? (aspirin, etc.)............................................................Yes / No

If yes, Please list ____________________________________________________________________________

Are you seeing any other doctor now for any reason? ........................................................................................Yes / No

If yes, please explain _________________________________________________________________________

(Women only) Do you have any reason to believe that you may be pregnant? ...................................................Yes / No

What operations have you had? Please include cosmetic surgery, breast implants, etc.

______________________________________________________________________________ Year _____________

SOCIAL HISTORY

Smoker?.............................Yes / No

If yes, how many packs a day? ____________ Years? ___________________

Alcohol?.............................Yes / No

If yes, how much? ______________________ Years? ___________________

FAMILY HISTORY

Did your mother or father have any of the following: Put an M for mother, F for father, and B for both.

___ High Blood Pressure

___ Ulcer or Stomach Problems

___ Heart Attack

___ Stroke (Please indicate age when stroke occurred)

___ Emphysema

Mother___ Father ___

___ Seizure/Convulsions

___ Arthritis

___ HIV Positive

___ Mental Illness

___ Asthma

___ Thyroid Disease

___ Diabetes

___ Circulation Problems

___ Kidney Disease

___ Cancer

Are you currently being treated or have you ever been treated for ANY condition not listed above? Please list the conditions

and treatment: _____________________________________________________________________

Patient signature: _ ________________________________________ D ate: _ __________________

Confidential Patient History Form - Noble Choice Chiropractic Page 2

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