Patient History Form (Page 2 of 2) in pdf

Page 2

P R E S E N T H I S T O R Y C O N T I N U E D

Name any other doctors seen for this problem: ____________________________________________________________________

List diagnosis(es) and types of treatment(s) given: __________________________________________________________________

_______________________________________________________________________________________________

Did this previous treatment help your condition?

❑ Yes ❑ No ❑ Temporarily

Have you had similar accidents or injuries before?

❑ Yes

❑ No

If yes, explain: ____________________________________________

Have you been treated for any health condition by a physician in the last year?

❑ Yes ❑ No If yes, explain: ____________________________

______________________________________________________________________________________________

Patient History of Cancer:

______________________________________Family History of Cancer:

_______________________

(type)

Medications taken presently: _____________________________________________________________________________

Have you ever been to a chiropractor before?

❑ Yes

❑ No

Name of Doctor: _____________________________________________

Place an "X" next to the items you presently, or have previously, suffered from:

HEAD & NECK

RESPIRATORY SYSTEM

NERVOUS-MUSCULAR-SKELETAL SYSTEM

___ Headaches: Frequency ___ / Week

___ Asthma

___ Neck Problems

___ Head Injury: Location: ______

___ Persistent Cough

___ Pain Between Shoulders

___ Light-headed

___ Pain When Breathing

___ Shoulder-Elbow-Hand Problems: Where: _______

___ Jaw Pain

___ Difficulty Breathing

___ Low Back Problems

___ Depression / Anxiety

___ Hip-Knee-Foot Problems: Where: _______

DIGESTIVE COMPLAINTS

___ Muscle Stiffness

___ Muscle Soreness

CIRCULATORY PROBLEMS

___ Abnormal Pain

___ Muscle Spasms

___ Anemia

___ Gas / Bloating

___ Numbness: Where: _______

___ Varicose Veins

___ Constipation / Diarrhea

___ Tingling: Where: _______

___ Chest Pain

___ Heartburn

___ Pain in Arms / Legs

___ High Blood Pressure

___ Nausea

___ Heart Disease

___ Excessive Weight Gain

(F) FAMILY HISTORY (P) PATIENT HISTORY

___ Cholesterol

___ Excessive Weight Loss

___ Ulcers

___ Cold Sores

___ Frequent Colds

___ Rheumatic Fever

___ Stroke

___ Diabetes

___ Heart Condition

___ Food Allergies

___ Arthritis

___ Environmental Allergies

FEMALES ONLY

Are you pregnant? ❑ No ❑ Yes: Months: ___

Date of last period: _______

Date of last OB/GYN appointment: _______

Number of children: ___

Number of miscarriages: ___

Draw in your areas of pain

on the figures.

Menstrual Cramping: ___

Menstrual Irregularity: ___ Increased Bleeding: ___

Hot Flashes: ___

I understand that I am responsible for payment of all services at the time rendered. If this is not acceptable, other arrangements must be made with the office in advance.

Patient Signature: ____________________________________________ Date: ________________________

(if patient is a minor, name of parent, guardian, etc..)

Patient History Form Page 2

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