ࡱ> \^[ Z!bjbjZZ ]8h8h4%X|kli""!!!!!!!$$&""#"!! 0!4z99R !9"0i"!,M'M'0!M'0!""""Oi"M' : Confidential Patient Case History Dear Patient: Please complete this questionnaire. Your answers will help us determine if chiropractic can help you. If we do not sincerely believe your condition will respond satisfactorily, we will not accept your case. THANK YOU. Name ___________________________________________________ Date _____________________ Please check the appropriate box for any of the following symptoms which you now have or have had previously. We want all the facts about your health before we accept your case. THIS IS A CONFIDENTIAL HEALTH REPORT. O OCCASIONAL F FREQUENT C CONSTANT O F C GENERAL ( ( ( Allergy ( ( ( Chills ( ( ( Convulsions ( ( ( Dizziness ( ( ( Fainting ( ( ( Fatigue ( ( ( Fever ( ( ( Headache ( ( ( Loss of sleep ( ( ( Loss of weight ( ( ( Nervousness/depression ( ( ( Neuralgia ( ( ( Numbness ( ( ( Sweats ( ( ( Tremors MUSCLE & JOINT ( ( ( Arthritis ( ( ( Bursitis ( ( ( Foot trouble ( ( ( Hernia ( ( ( Low back pain ( ( ( Lumbago ( ( ( Neck pain or stiffness ( ( ( Pain between shoulders Pain or numbness in: ( ( ( Shoulders ( ( ( Arms ( ( ( Elbows ( ( ( Hands ( ( ( Hips ( ( ( Legs ( ( ( Knees ( ( ( Feet ( ( ( Painful tail bone ( ( ( Poor posture ( ( ( Sciatica ( ( ( Spinal Curvature ( ( ( Swollen joints O F C GASTRO-INTESTINAL ( ( ( Belching or gas ( ( ( Colitis ( ( ( Colon trouble ( ( ( Constipation ( ( ( Diarrhea ( ( ( Difficult digestion ( ( ( Distension of abdomen ( ( ( Excessive hunger ( ( ( Gall bladder trouble ( ( ( Hemorrhoids ( ( ( Intestinal worms ( ( ( Jaundice ( ( ( Liver trouble ( ( ( Nausea ( ( ( Pain over stomach ( ( ( Poor appetite ( ( ( Vomiting ( ( ( Vomiting of blood EYES, EARS, NOSE &THROAT ( ( ( Asthma ( ( ( Colds ( ( ( Crossed eyes ( ( ( Deafness ( ( ( Dental Decay ( ( ( Earache ( ( ( Ear discharge ( ( ( Ear noises ( ( ( Enlarged glands ( ( ( Enlarged thyroid ( ( ( Eye pain ( ( ( Failing vision ( ( ( Far sightedness ( ( ( Gum trouble ( ( ( Hay fever ( ( ( Hoarseness ( ( ( Nasal obstruction ( ( ( Near sightedness ( ( ( Nosebleeds ( ( ( Sinus infection ( ( ( Sore throat ( ( ( Tonsillitis O F C CARDIO-VASCULAR ( ( ( Hardening of arteries ( ( ( High blood pressure ( ( ( Low blood pressure ( ( ( Pain over heart ( ( ( Poor circulation ( ( ( Rapid heart beat ( ( ( Slow heart beat ( ( ( Swelling of ankles RESPIRATORY ( ( ( Chest pain ( ( ( Chronic cough ( ( ( Difficult breathing ( ( ( Spitting up blood ( ( ( Spitting up phlegm ( ( ( Wheezing SKIN ( ( ( Boils ( ( ( Bruise easily ( ( ( Dryness ( ( ( Hives or allergy ( ( ( Itching ( ( ( Skin eruptions (rash) ( ( ( Varicose veins GENITO-URINARY ( ( ( Bed-wetting ( ( ( Blood in urine ( ( ( Frequent urination ( ( ( Inability to control kidneys ( ( ( Kidney infection or stones ( ( ( Painful urination ( ( ( Prostate trouble ( ( ( Pus in urine FOR WOMEN ONLY ( ( ( Congested breasts ( ( ( Cramps or backache ( ( ( Excessive menstrual flow ( ( ( Hot flashes ( ( ( Irregular cycle ( ( ( Menopausal symptoms ( ( ( Painful menstruation ( ( ( Vaginal discharge ( Yes ( No Are you pregnant?  CHECK THE FOLLOWING CONDITIONS YOU HAVE HAD: ( Alcoholism ( Anemia ( Appendicitis ( Arteriosclerosis ( Arthritis ( Cancer ( Chorea ( Cold sores ( Diabetes ( Diphtheria ( Eczema ( Emphysema ( Epilepsy ( Fever blisters ( Goiter ( Gout ( Heart disease ( Influenza ( Lumbago ( Malaria ( Measles ( Miscarriage ( Multiple sclerosis ( Mumps ( Pleurisy ( Pneumonia ( Polio ( Rheumatic fever ( Scarlet fever ( Stroke ( Tuberculosis ( Typhoid fever ( Ulcers ( Venereal disease ( Whooping cough PLEASE PRINT List surgical operation and years: _______________________________________________________________________ ___________________________________________________________________________________________________ Drugs you now take: ( Nerve pills ( Pain killers ( Muscle relaxers ( Pep pills ( Tranquilizers ( Birth control pills Others: _____________________________________________________________________________________ Age of mattress: ___________________ ( Comfortable ( Uncomfortable ( Do you use a bed board? _________ Are you wearing: ( Heal lifts ( Sole lifts ( Inner soles ( Arch supports Have you ever had any mental or emotional disorders? ( Yes ( No When? ____________________________ Have others in your family had such disorders? ( Yes ( No When? _____________________________ HAVE YOU EVER: Been knocked unconscious? Used a cane, crutch, or other support? Been treated for a spine or nerve disorder? Had a fractured bone? Been hospitalized for anything other than surgery?  Yes No ( ( ( ( ( ( ( ( ( (  DESCRIBE BRIEFLY ___________________________________________________________________________________________________________________________________________________________________________________________________ DO YOU: Now take vitamins or minerals? Think you may need vitamins or minerals? Have an allergy to any drug?  ( ( ( ( ( (  _____________________________________________________________________________________________________________________ DATE OF LAST: Spinal examination Physical examination Blood test Chest X- ray Spinal X-ray Dental X-ray Urine test  Less than 6 months ( ( ( ( ( ( (  6-18 months ( ( ( ( ( ( (  Over 18 months ( ( ( ( ( ( (  Never ( ( ( ( ( ( ( HABITS Alcohol Coffee Tobacco Drugs Exercise Sleep Appetite  Heavy ( ( ( ( ( ( (  Moderate ( ( ( ( ( ( (  Light ( ( ( ( ( ( (  None ( ( ( ( ( ( ( IN CASE OF EMERGENCY: (Name of relative or close friend not living in your home): NAME ___________________________________________________________________________________________ ADDRESS: _______________________________________________________ PHONE: ________________________     PAGE  PAGE 1 "#  E I ` 7 : d m n z { } ~ ÿÿhaCJaJ jhaCJaJha5CJaJhT#.5CJaJhT#.CJaJhT#.hT#.CJaJhT#.h_hT#.CJaJ hT#.6h 36CJaJh_hT#.6CJaJh_hT#.CJaJhT#.hv5CJ(aJ(5"# ` 8 9 : I V c d n z  ' @ a u @&gdagdT#.$a$gdv $@&a$gda         ' ( * + - . @ A C D F G a b d e g h u v x y { |     hYhYiN5CJaJ jhYiNCJaJhYiNCJaJ jhaCJaJhaCJaJQu  & 8 Y z  / K e x `gdS6gdT#.       & ' ) * , - 8 9 ; < > ? 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