Health History Form

Fill out this form, print it, and bring it with you on your first visit to our office.

CASE NO. 
Date:
Please fill out the following form with as much detail as possible.

Name:

Address:


City:
State:
Zip:
Home Number:
Office Number:
E-mail Address:
Age: Date of Birth: Occupation: Sex: Male Female
Weight:

Referred By:

Married S W D Children:
Name of Spouse:
Employer:
Address:
Is any other member of your family being treated in this office? Yes No
Have you ever had chiropractic care before? Yes No
For what problem?
 Were the results satisfactory? Yes No N/A
Major complaints and symptoms - please be as specific as you can. Ask the doctor or nurse for help if you need assistance in filling out this section.

How do you believe your problem (pain) began?

 

 

When did you first notice this problem / pain?
Have you lost any work? Yes No

Day and date you last worked:

Have you ever had this condition before or a similar condition? Yes No
When?
What positions or activities aggravate your condition?
What positions or activities relieve your condition?
Have you been treated by a Medical Physician for this ailment? Yes No
Where?
Describe the type of treatment:
Diagnosis of previous physician:
Length of time under care: Results:

Family physician's name:

Please send a report to my family physician. Yes No

Will this case be covered by any insurance company?
Major Medical Auto Blue Cross / Blue Shield Workers' Compensation
Medicare Other

Have you ever been in any accidents, auto, fall down stairs, fall from ladder, etc (include childhood injuries)?
Yes No

When?
Are you allergic to anything you are aware of? Yes No
Are you presently taking any medication (aspirin included)? Yes No
If "Yes", name them:
Have you ever broken any bones? (fractures) Yes No Any dislocations? Yes No
What operations have you had? Year
Year
Year
Have you had any cosmetic surgery, breast implants. etc.? Yes No Year
Have you had any surgery to replace hip, knee, etc.? Yes No Year

 

Give dates you have had any of the following: (if exact date is unknown, give approximate date)
Blood Test
Urinalysis
MRI CT Scan
Ultrasound
Radiation Treatment
X-Ray examination
Other special treatment:
At what hospital or office were these tests taken at?
Name of doctor who ordered tests :
Date of last menstrual period :
Do you have any reason to believe that you may be pregnant? Yes No
Do you have any health problems not listed above? Yes No
Do you faint easily? Yes No
Do you take vitamins? Yes No If Yes, please list them
Do you exercise regularly? Yes No What kind of exercise?
Habits: (please check)      
Cigarettes? Quantity Coffee? Quantity
Alcohol? Quantity Tea? Quantity
Hobbies:
Have you been treated for any health condition by a physician in the past year? Yes No
If Yes, what condition?
Have you lost or gained weight in the past year? Yes No

Use this space for any additional information you may wish to discuss:

 

Have you had or do you now have any of the following symptoms which are or have been of significant distress to you? Please indicate with the letter N if you have these conditions now (within the past 12 months) or P if you ever had these conditions in the past (prior to the past 12 months).

 

Now
N
Past
P
Now
N
Past
P
Headaches_____ Frequency
Loss of Balance
Neck Pain
Fainting
Stiff Neck
Loss of Smell
Sleeping Problems
Loss of Taste
Back Pain
Diarrhea
Nervousness
Feet Cold
Tension
Hands Cold
Irritability
Arthritis
Chest Pains
Muscle Spasms
Dizziness
Frequent Colds
Shoulder / Neck / Arm Pain
Stomach Upset
Pins & Needles in Arms
Constipation
Pins & Needles in Legs
Cold Sweats
Numbness in Fingers
Fever
Numbness in Toes
Sinus Problems
High Blood Pressure
Diabetes
Difficulty Urinating
Hemorrhoids
Allergies
Leg Cramps
Weakness in Arms
Colitis
Weakness in Legs
Gall Bladder
Shortness of Breath
Indigestion
Fatigue
Belching
Depression
Vomiting
Lights Bother Eyes
Shoulder Pain
Loss of Memory
Swelling Joints
Ears Ring
Knee Pain
Face Flushed
Hay Fever
Buzzing in Ears
Menstrual Difficulties

I understand and agree that health and accident insurance policies are an agreement between the insurance carrier and myself, and that all services rendered me are charged directly to me, and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, and fees for professional services rendered me will be immediately due and payable.
 

 

             
  Do you have chest pain? Yes No
  Do you have any change in bowel or bladder habits? 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 any thickening in your breasts or elsewhere? Yes No
  Do you have indigestion or difficulty in swallowing? Yes No
  Do you have a change in any wart or mole? Yes No
  Do you have a nagging cough or hoarseness? Yes No
  Do you have headaches for hours or days? Yes No
  Do you have blurred vision? Yes No
  Do you have night sweats? Yes No
  Do you have pain in neck, jaw, or face? Yes No
  Do you have a drooping eyelid or any change in your pupils? Yes No
  Do you have vertigo (dizziness)? Yes No
  Do you have double vision? Yes No
  Do you have any other visual disturbances? Yes No
  Do you have any nausea or vomiting? Yes No
  Do you have any slurred speech? Yes No
  Do you have any ringing in your ears? Yes No
  Do you pass out easily (faint)? Yes No
  Do you take birth control pills? Yes No
  Do you have a history of stroke in your family? Yes No
  What prescription medication are you taking if any?  
    High blood pressure medication  
    Blood thinners  
    Other
    List allergies or adverse reactions to medications.
     

 

 

Have you ever had cancer? Yes No
Does your pain ever wake you from a sound sleep? Yes No
Are you losing weight now without trying? Yes No
Are you coughing up blood or noticing it in your stools or urine? 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
Are you seeing any other doctor now for any reason? Yes No
Notes:  
Are you taking any medications or over-the counter drugs? Yes No
Please indicate type (aspirin, etc.)
What was the date of onset of your last menses?
SOCIAL HISTORY
Smoker YES, or NO (If "Yes", how many packs, and frequency)
Alcohol YES, or NO (If "Yes", how much drank, which liquid, and frequency)
FAMILY HISTORY
Has your mother or father had any of the following:
Put an M for mother, F for father, and B for both
M
F
B
M
F
B
High Blood Pressure Ulcer or Stomach Problems
Heart Attack Stroke
Emphysema Arthritis - Rheumatism
Seizures-Convulsions Mental Illness
HIV Positive Thyroid Disease
Asthma Circulation Problems
Diabetes Cancer
Kidney Disease Osteoporosis
Pacemaker        

Comments:

Print this form and bring it with you on your first visit to our office.