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New Patient Health History Please print clearly and answer questions as completely as possible Patient Name: ____________________ Male Female Single Height: ______________ D.O.B:___/____/____ Age: _____ Date: ___/____/____ Married Other Weight: _________________ Occupation: ___________________ 1. What are your main areas of complaint? ____________________________________________ __________________________________________________________________________________ 2. How and when did your problem begin? __________________________________________________________________________________ __________________________________________________________________________________ 3. How often do you experience symptoms? Constantly (76-100% of the time) Occasionally (26-50% of the time) Frequently (51-75% of the time) Intermittently (0-25% of the time) 4. How are your symptoms changing with time? Getting Worse Staying the Same Getting Better 5. Using a pain scale from 0-10 (10 being the worst), how would you rate your problem? 0 1 2 3 4 5 6 7 8 9 10 (Please circle) 6. Has this codition interfered with your work, social activities or sleep?____________________ 7. Who else have you seen for this condition? _________________________________________ _________________________________________________________________________________ 8. What makes your symptoms better?_________________________________________________ 9. Does anything make your symptoms worse? ___________________________________________ 10. What type of exercise do you do? Strenuous Moderate Light None 11. List all medications and supplements you are currently taking or have taken for extended periods:___________________________________________________________________________ __________________________________________________________________________________ 12. List all surgical procedures, serious illnesses and hospitalizations you have had and approximate dates:_________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 13. Have you had significant past injuries/accidents? Yes No If yes, please explain: _________________________________________________________________________________________ __________________________________________________________________________________ 14. Do you have any health problems? ________________________________________________ Evolve Wellness, LLC, Kelly Barrett, DC 3125 E. Burnside St. Portland, OR 97214 (503)758-9760 For each of the conditions listed below, place a check in the “PAST” column if you have had the condition in the past. If you presently have a condition listed below, place a check in the “PRESENT” column. Past Present Past Present Past Present Headaches Neck Pain Upper/Mid Back Pain Scoliosis Low Back Pain Shoulder Pain Elbow/Upper Arm Pain Wrist/Hand Pain Hip Pain Knee/Leg Pain Ankle/Foot Pain Jaw Pain Herniated Disc Concussion/Head Injury Arthritis Autoimmune Disease Slow Healing Liver/Gallbladder Disorder Nerve Damage High Blood Pressure Heart Disease High Cholesterol Stroke/Aneurysm Kidney Disorders Osteoporosis Bleeding Disorder Anticoagulant Therapy Corticosteroid Therapy Bladder Control Loss Prostate Problems Ulcer Infection/Fever Mental Health Issues Dizziness/Fainting Cancer/Tumor Blood Clot Numbness/Tingling/Weakness Pregnancy Diabetes Gastrointestinal/Bowel Issues Drug Abuse/Addiction Smoking/Tobacco Use Alcoholism Allergies Depression Fractures Chronic Cough Dermatitis/Rash/Eczema HIV/AIDS Anemia Thyroid Problems Asthma Anorexia Loss of Appetite Abnormal Weight Gain/Loss Metal/Surgical Implants Please Mark area(s) of injury or discomfort using (A) Letters to describe your pain (B) Numbers for the degree of pain using a scale from 1 (discomfort) to 10 (extreme pain) N = Numbing P = Pins and Needles B = Burning A = Aching S = Stabbing Is there anything else you feel is pertinent to today’s visit?__________________________________ ___________________________________________________________________________________ Patient Signature:_______________________________________________________________ Evolve Wellness, LLC, Kelly Barrett, DC 3125 E. Burnside St. Portland, OR 97214 (503)758-9760
