Survey
* 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
Dr. Jane Torrie, Chiropractor Name_________________________________________________ Date_______________________________ Street Address______________________________________________________________________________________ City ___________________________ State_______ Zip___________ Email Address _____________________________ H. Phone _______________________ Cell Phone_____________________ Date of Birth___________ Age__________ Referred by________________________ Occupation______________________ Employer_______________________ Marital Status S M D W Spouse Name_______________________________________ Number of Children/Ages_________________________ Spouse’s Occupation__________________________________ Have you ever received Chiropractic Care? Yes No _______________________________________ Are you using insurance? _________________________ Through employer? Y N About Your Health The human body is designed to be healthy. Throughout life, events occur that can damage your health expression. This case history may help uncover layers of damage, especially to your nervous system and spine, which can result in poor health. Following your assessment, I will outline a course of care to begin to correct these layers of damage and to help you recover your inborn/innate health potential. Loss of Wellness Please circle for each of the following: Patient Comment Chiropractor’s Comments 1. Health history: Childhood illnesses? Ear infections/ Colic/ Asthma? Attention Deficit? Accidents? Surgery? Did you fall down stairs? Chair pulled out when sat down? Were you yanked by your arm? Did you have other traumas? Did you ever break any bones? Y Y Y Y Y Y Y Y Y Y N N N N N N N N N N _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ 2. Current Health Habits: Did/do you smoke? Did/do you drink alcohol? Did/do you use caffeine? Y Y Y N _______________ N _______________ N _______________ _____________________ _____________________ _____________________ Patient History Form Page 1 Dr. Jane Torrie, Chiropractor Diet, do you eat healthy foods? Y N _______________ How much water do you drink? _______________ Have you been in accidents/trauma? Y N _______________ Have you had surgery? Y N _______________ Teeth problems? Y N _______________ Eye problems? Y N _______________ Hearing problems? Y N _______________ Exercise regularly? Y N _______________ Do you sleep well? Y N _______________ Did/do you have occupational stress? Y N _______________ Physical stress? Y N _______________ Emotional/Mental stress? Y N _______________ Hobbies/Sports injuries? Y N _______________ Sleeping posture? O side O stomach O back _______________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ Symptoms and Present State of Health Previous years of unnoticed and or unattended damage to the nervous system and spine may show up as acute or chronic symptoms. Present Complaint/Reason for Seeking Care in this Office: __________________________________________________________________________________________ Pain or Problem started on____________________________________________________________________ Pains are: O Sharp O Dull/ Ache O Constant O Intermittent O Other_________________ Does this pain shoot, radiate, or travel in your body? ___ yes ____ no Where?____________________________________________________ Are you experiencing numbness or tingling in any area of your body? ? ___ yes ____ no Where?______________________________________ What activities aggravate your condition or pain? _________________________________________________________________________________________ ___________________________________________________________________________________________ What activities lessen your condition or pain? _________________________________________________________________________________________ ___________________________________________________________________________________________ Is this condition worse during certain times of the day?_______________________________________________ Is this condition interfering with work?______ Sleep?_ ____ Routine?_______ Other?____________________ Is this condition progressively getting worse? ____________________________________________________ Please Circle how you feel today: (No Complaint/Pain) 0 1 2 3 4 5 6 7 8 9 10 (Worst Possible Complaint/Pain) Other Doctors seen for this condition ____________________________________________________________ Any home remedies? _________________________________________________________________________ Please mark any of the following that you have now or have experienced: Other Symptoms: Patient History Form Page 2 Dr. Jane Torrie, Chiropractor O Headaches O Neck Pain O Sleeping Problems O Low Back Pain O Nervousness O Tension O Irritability O Dizziness O Pain between Shoulders O Neck Stiff O Joint Swelling O Fever O Loss of Balance O Pain in Hands or Arms O Numbness in Hands or Arms O Pain in Legs or Feet O Numbness in Legs or Feet O Fatigue O Depression O Lights Bother Eyes O Loss of Memory O Shoulder Pain O Sinus O Shortness of Breath O Asthma O Allergies O Chest Pains O Heart Attack O High Blood Pressure O Stroke O Cancer O Painful Urination O Diabetes O Diarrhea O Constipation O Stomach Upset O Menstrual Cramps O Weight Loss O Loss of Smell or Taste What other conditions do you have? ________________________ __________________________________ Have you been under drug and medical care?________________________ __________________________________ What Medications are you taking?__________________________ __________________________________________ How long?_________________ Have you had surgery?_________________ What?_________________ When?_________________ Have you experienced side effects from the drugs and surgery? _________________________________________ _____________________________________________________________________________________________ Females Only – Date last Menstrual Period began on_________________ Are you possibly Pregnant?___________ Male only – Prostate issues ______________________________________________________________________ Is there a family History of: Heart Disease Arthritis Cancer Diabetes Other__________________ Father’s side O O O O O ____________________ Mother’s side O O O O O ____________________ About Your Care Chiropractic patients often experience several stages of treatment. The first is initial intensive care, which corrects the most recent layer of spinal and neurological damage. This care often reduces or eliminates the symptoms. Then reconstructive care begins, which corrects the years of damage that occurred when there were few symptoms. Finally, Chiropractic offers a genuine approach to Wellness Care. If you have questions about any of these options please ask. Then you’ll be able to begin a course of care that fits your goals. I have read the above information and certify it to be true and correct to the best of my knowledge, and hereby authorize this office of Chiropractic to do whatever is necessary in accordance with this state’s statues, to provide me with chiropractic care. I understand that I am financially responsible for all charges for services and agree to make payment and provide insurance information when appropriate. Signature______________________________________________________ Patient or Guardian Patient History Form __________________________ Date Page 3