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* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Welcome to our office! You’re going to love it here! _________________________________________________________________________________________________________________ Today’s Date: ___ /___ /________ We love our patients. Who may we thank for referring you here? ______________________________________________________ Patient Information: First Name: _____________________________ Middle Name: ____________________________ Last Name: ________________________ SSN: _____________________________________ Date of Birth: ____________________________ Sex: Male Female Marital Status: Single Married Divorced Widowed Spouse’s Name: _____________________ # of Children: _______ Home #: __________________________________ Cell #: _____________________________________ Work #: ____________________________ Address: _____________________________________________________________________________________________________________________________ City: _______________________________________ State: ______________________________________ Zip Code: ___________________________ Emergency Contact: _____________________ Emergency Relation: _____________________ Emergency Phone: ________________ E-mail: _____________________________________________________________________________________ Employer Information: Employed: Full Time Part Time Retired Student Unemployed Employer Name:____________________________________________________________________________________________________________________ Employer Address:_________________________________________________________________________________________________________________ Employer City:____________________________ Employer State:___________________________ Employer Zip:______________________ Occupation:_______________________________ Work Supervisor:_________________________ Supervisor #:_______________________ Work Duties:________________________________________________________________________________________________________________________ Insurance Information Insurance Worker’s Comp Self-Pay (Cash) Personal Injury/Auto Other (explain):_____________________ Primary Name:_______________________ Primary Phone:_____________________________ Primary DOB:______________________ Address:_____________________________________________________________________________________________________________________________ City:________________________________________ State:________________________________________ Zip Code:___________________________ ID/Policy #:_______________________________ Group #:____________________________________ Secondary Name:_________________________ Secondary Phone:__________________________ Secondary DOB:____________________ Address:_____________________________________________________________________________________________________________________________ City:________________________________________ State:________________________________________ Zip Code:____________________________ ID/Policy #:_______________________________ Group #:____________________________________ Claim #:____________________________________ Claim Contact:______________________________ Claim Phone:_______________________ Attorney Name:_____________________________________________________________________________ Attorney Phone:____________________ ----------------------------------------------------------------------------------------------------------------------------- -------------------------Who is responsible for payment? Self / Other – (Relationship) ______________________________________ Other than self: Full Name: _________________________________________________ Phone: ____________________________________ Address: __________________________________________ City: ________________________ State: _______________ Zip: _____________ It is usual and customary to pay for services as rendered unless otherwise arranged. Patient #: ____________________ Love Chiropractic LLC 1 History of Current Condition Describe Major Complaint: ________________________________________________________________________________________________________ Began When?: ___/___/______ Describe how this began: _________________________________________________________________________ _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ Grade Intensity/Severity of Complaint: (Circle) None / Mild / Moderate / Severe / Very Severe Quality of the complaint/pain: Sharp / Stabbing / Burning / Achy / Dull / Stiff & Sore / Other: ________________________ How frequent is the complaint present? (Circle) Off & On / Constant Does this complaint radiate/shoot to any areas of your body? No / Yes (Describe) _________________________________________ Head- Base of Skull / Forehead / Sides-Temple Arm- Across Shoulder / Elbow / Hand-Fingers R / L / Both R / L / Both Leg- Hip / Thigh-Knee / Calf / Foot-Toes R / L / Both Other Area: _____________________________________________________________ Does anything make the complaint better? Ice / Heat / Rest / Movement / Stretching / OTC / Other: ________________ Does anything make the complaint worse? Sit / Stand / Walk / Lying / Sleep / Overuse / Other: _____________________ Which daily activities are being affected by this condition? (Describe) ___________________________________________________ For this CURRENT condition, have you: - Received any other treatment? None / DC / MD / PT / Massage / ER / Other: __________ Where? _____________ - Had any previous Surgery or Interventions in this area? (Describe) ____________________________________________ - Taken any Medications? OTC / Prescriptions ________________________________________________________________________ - Had any diagnostic testing? X-Ray / MRI / CT / Other: __________________ When & Where? ________________________ Please describe any secondary complaints: _____________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ Please indicate where your pain is: Patient #: _____________________ Love Chiropractic LLC 2 Health History: (Please use the reverse side of this page if additional space is needed) Medications: (Please list the medication and the dosage, include vitamins and supplements) Medications Dosage Medications Dosage ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ Please list Allergies and your Reaction to the Allergy: Allergy:_____________________________________________________ Allergy:_____________________________________________________ Allergy:_____________________________________________________ Allergy:_____________________________________________________ Reaction:___________________________________________________ Reaction:___________________________________________________ Reaction:___________________________________________________ Reaction:___________________________________________________ Past Surgical History: (Include date, surgeon’s name, type of surgery and any complications) _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ Past Hospitalizations: (Date, complications, and cause of hospitalizations) _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ Major Hospitalizations: None ____________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ Family Health History: (Please mark N/A if not relevant.) List relevant major health problems of immediate relatives: _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ Deaths in immediate family: (Cause and at what age?) _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ Social & Occupational History: _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ Level of Education Completed: _______________________________ High School / Some College / College Graduate / Post Graduate / Other Lifestyle: (Hobbies, Rec. Activities, Exercise, Diet, Work, Vitamins) _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ Habits: Cigarettes – (#/day) _______________________________________________________________________________________________________________ Alcohol – (amount/day) ___________________________________________________________________________________________________________ Coffee / Tea – (cups/day) __________________________________________________________________________________________________________ Rec. Drug (List) ____________________________________________________________________________________________________________________ Patient #: ___________________________ Love Chiropractic LLC 3 Review of Systems: Are you currently experiencing any of these symptoms? (Check all that apply) Many of the following conditions respond to Chiropractic Care! General: (constitutional) Recent Weight Change Fever Fatigue None in this Category Musculoskeletal: Low Back Pain Mid Back Pain Neck Pain Arm Problems___________________ Leg Problems ___________________ Painful Joints Stiff/Swollen Joints Sore/Weak Muscles or Joints Muscle Spasms/Cramps Broken Bones: __________________ Other: ___________________________ None in this Category Neurological: Numbness or Tingling Sensations Loss of Feeling Dizziness or Light Headed Frequent or Recurrent Headaches Convulsions or Seizures Tremors Stroke Have you ever had a head injury? Ever been in an auto accident? Other: _______________________________ None in this Category Mind/Stress: Nervousness Depression Sleep Problems Memory Loss or Confusion Other: _______________________________ None in this Category Genitourinary: Sexual Difficulty Kidney Stones Burning/Painful Urination Change in Force/Strain with Urination Frequent Urination Blood in Urine Incontinence or Bed Wetting Other: ________________________________ None in this Category Gastrointestinal: Loss of Appetite Blood in Stool Change in Bowel Movements Painful Bowel Movements Nausea or Vomiting Abdominal Pain Frequent Diarrhea Constipation Other: _______________________ None in this Category Cardiovascular & Heart: Chest Pains Rapid or Heartbeat Changes Blood Pressure Problems Swelling of Hands, Ankles, or Feet Heart Problems Other: _______________________________ None in this Category Respiratory: Difficulty Breathing Persistent Cough Coughing Blood Asthma or Wheezing Lung Problems Other: _______________________________ None in this Category Eyes & Vision: Wear Contacts/Glasses Blurred or Double Vision Glaucoma Eye Disease or Injury Other: _______________________________ None in this Category Ears, Nose, & Throat: Bleeding Gums / Mouth Sores Irregular Bad Breath or Bad Taste Dental Problems Swollen Throat or Voice Change Swollen Glands in Neck Ringing in the Ears Ear-Ache/Ringing/Drainage Sinus / Allergy Problems Nose Bleeds Hearing Loss Other: ________________________________ None in this Category Endocrine, Hematologic, & Lymphatic: Thyroid Problems Diabetes Excessive Thirst or Urination Cold Extremities Heat or Cold Intolerance Change in Hat or Glove Size Dry Skin Glandular or Hormone Problems Swollen Glands Anemia Easily Bruise or Bleed Phlebitis Transfusion Immune System Disorder Other: _______________________________ None in this Category Skin & Breasts: Rash or Itching Changes in Skin Color Change in Hair or Nails Non-healing Sores Change of Appearance of a Mole Breast Pain Breast Lump Breast Discharge Other: ______________________________ None in this Category Women Only: Are You Pregnant? Yes – Due Date ___/___/_____ No – Last Menstrual Period ___/___/_____ Infertility Painful or Irregular Periods Vaginal Discharge Other: _______________________________ None in this Category Pregnancies with Outcome & Date: __________________________________________ __________________________________________ __________________________________________ __________________________________________ Anything else not mentioned previously that the doctor should be aware of: _______________________________________________________________ _______________________________________________________________________________________________________________________________________________________ I have read the above information and certify it to be true and correct to the best of my knowledge, & hereby authorize this office to provide me with chiropractic care, diagnostic testing, and/or therapeutic services, in accordance with this state’s statues. Patient or Guardian Signature: ________________________________________________________________ Treating Doctor Signature: ____________________________________________________________________ Date: ___________________________________ Date: ___________________________________ Patient #: ________________________ Love Chiropractic LLC 4