Confidential Patient Case History Form
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Confidential Patient Case History Form
Please print clearly
Date __________________
Name _____________________________________________________
Male
Female
Address __________________________________
City _____________________ Prov ____________
Postal Code _______________ Home Phone: ____________________ Work Phone: ___________________
Birth Date: ________(m) ________(d) ________(y)
Occupation: _______________________________
Medical Doctor: ___________________________
Doctor Phone #: ____________________________
How did you hear about us? __________________________________________________________________
Please indicate conditions you are experiencing or have experienced:
Cardiovascular
Respiratory
Digestive
High blood pressure
Asthma
Constipation
Low blood pressure
Bronchitis
Chrones Disease
Chronic congestive heart failure
Emphysema
Colitis
Heart attack
Chronic Cough
Irritable Bowel Syndrome
Phlebitis / varicose veins
Shortness of breath
Ulcers
Stroke / CVA
Pacemaker or similar device
Is there a family history of any of the
Heart disease
above?
Yes
No
Dizziness / vertigo
Seizures
Is there a family history of any of the above?
Yes
No
Head and Neck
Muscle/Joint
Other
History of headaches
Neck
Loss of sensation
History of migraines
Back (lower)
Where? ____________________
Vision problems
Back (mid)
Diabetes
Vision loss
Back (upper)
Onset: _____________________
Ear problems
Shoulders
Type: ______________________
Hearing loss
Elbow
Allergies / hypersensitivity
Wrist / Hand
What? _____________________
Hip
Epilepsy
Knee
Cancer
Ankle / Foot
Type/Location: _______________
Spine
Arthritis
Is there a family history of
arthritis?
Yes
No
Hemophilia
Fibromyalgia
Women
Infectious Conditions
Chronic fatigue
Pregnancy
Skin Conditions
Due Date: ______________________
Describe: ______________________
Scoliosis
Polio / Post Polio
Previous pregnancy complications
Respiratory Conditions
Osteoporosis
_______________________________
Describe: ______________________
Hepatitis
_______________________________
Men
Menopausal problems
Enlarged Prostate
_______________________________
Libido Issues
Skin Conditions
Menstrual problems
Other
Eczema
_______________________________
_________________________
Psoriasis
Gynecological conditions
Rash
Describe: _______________________
Warts
Open Sores
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Parent category: Medical