Download Comprehensive Personal History Personal Information

Comprehensive Personal History
Personal Information
Date______________________
Name_____________________________________Name I Prefer To Be Called_____________________
Address______________________________________City_____________________________________
State____________ Zip____________ Date of Birth_____________ Occupation____________________
Home phone________________________________ Cell Phone_________________________________
E-mail Address_________________________________________________________________________
Relationship Status____________________________Ages of Children____________________________
Height__________ Weight__________ Referred By____________________________________________
Main Health Concern
What Is Your Main Health Concern?________________________________________________________
_____________________________________________________________________________________
How Long Have You Had This Condition? ____________ Have You Been Diagnosed By a
Doctor?_______
How Long Has It Been Since You Really Felt
Good?____________________________________________
What Do You Believe Is Wrong With
You?____________________________________________________
Do You Have Any Trauma or Loss in the Last 5
years?__________________________________________
Do You Receive Regular Chiropractic Care?__________ Get Yearly Physical Exams?________________
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Family Health Information
Relationship
Past and Present Health Problems
____________________
___________________________________________________________
____________________
___________________________________________________________
____________________
___________________________________________________________
____________________
___________________________________________________________
Prescription Medications
Name of Drug
Reason for Use
For How Long?
___________________
_______________________________________
_____________
___________________
_______________________________________
_____________
___________________
_______________________________________
_____________
___________________
_______________________________________
_____________
___________________
_______________________________________
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Medical Treatment
For What Conditions Have You Ever Been Hospitalized or Undergone Surgery?______________________
_____________________________________________________________________________________
Date of Last Colonoscopy?_________ Mammogram?________ PAP__________ Physical?____________
Please Explain Any Abnormal Results_______________________________________________________
_____________________________________________________________________________________
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Females Only
Number Of Pregnancies? ___________________ Are You Pregnant or Nursing? _______________
Date Of Last Period?____________________
Have You Had A Hysterectomy? ______________
Are You Experiencing Any Problems With Your Period?________________________________________
Are You Experiencing Any Post-menopausal Symptoms? _______________________________________
Self Assessment
How Do You Grade Your Physical Health?
Excellent Good
Fair
Poor
Improving
How Do You Grade Your Emotional Health? Excellent Good
Worsening
Fair
Poor
Improving
Worsening
Please Rate Your Current Stress Level From 1-10
(low)
1
2
3
4
5
6
7
8
9
10 (high)
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10 (high)
Please Rate Your Current Energy Level From 1 - 10
(low) 1
2
3
4
5
6
7
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What Times Do You Generally Go To Bed and Get Up?
_________________________________________
Do you have Trouble Falling Asleep? ___________________ Staying Asleep?______________________
What Sleep Aids Do You Use?___________________ Do You Wake Feeling Rested? ________________
Do You Have An Energy Dip In The Afternoon? ____________ Use Coffee/Candy for Energy?__________
Have Much Water Do You Drink Each Day?______________ What Kind? __________________________
How Many Cups Of Coffee Do You Drink Each Day?_________________ Decaf or not?_______________
How Many Cups Of Tea Do You Drink Each Day?__________________ Type of
Tea?_________________
How Many Soft Drinks Do You Drink Each Day?___________________ Diet or Regular?______________
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How Many Glasses Of Alcohol?________________ Juice?_________________Milk?_________________
Do You Use Energy Drinks? ___________________ Sports Drinks?________________________
Please Circle What Best Describes Your Diet:
Vegetarian
Vegan
Low Fat
Low Carb
High in Processed/Fast Food High Carb
Other
Please Give Examples Of Your Typical Meals:
Breakfast_____________________________________________________________________________
Lunch________________________________________________________________________________
Dinner________________________________________________________________________________
Snacks_______________________________________________________________________________
Please Describe Any Food Cravings You Have (For specific foods such as bread or chocolate, or types of
food such as salty, sweet or
crunchy)________________________________________________________
_____________________________________________________________________________________
Please List Any Foods That You Know Negatively Affect You In Any
Way____________________________
_____________________________________________________________________________________
How Often Do You Have A Bowel Movement?_________________ Easy To Pass?
___________________
Do You Have To Use Anything To Make Your Bowels Move?_____________________________________
Are Your Stools Ever (please circle)
very light brown
yellowish
greenish
white/tan
Ever Had a Gallbladder Attack?_________ Do You Avoid Fatty Food Because of
Discomfort?___________
Do You Have A Regular Spiritual Practice? If So, What?________________________________________
Do You Have Stress From: (check all that apply)
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____Marriage ____School
____Career ____ Finances ____Family ____Health ____Spiritual Life
Other____________________________________________________________________________
________________________________________________________________________________
Do You Struggle With Weight?____________________________
Is There Anything Else You Would Like For Us To Know About You Or Your Condition?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Thank you for contacting our office to partner with you in your healthcare needs. Please do not hesitate to
ask questions or let us know if there is anything we can do to better support you.
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Authorization For Treatment
I herby authorize Dr. Douglas Portmann, D.C. of Wards Corner Chiropractic, to treat my condition as
deemed appropriate through the use of chiropractic manipulation, nutritional therapy, physiotherapy and/or
other natural, drug-free methods.
I understand that Gina Perry’s services are for educational purposes only and that I choose to be an active
participant in my health choices.
I understand and agree that I am responsible for payment of all services at the time of my visit unless prior
arrangements have been made.
Patient Signature_______________________________________________ Date___________________
Or, If Appropriate, Parent/Guardian Signature_________________________________________________
Parent/Guardian’s Printed Name__________________________________ Date___________________
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