Download CHIEF COMPLAINT and CONFIDENTIAL PATIENT HISTORY

CHIEF COMPLAINT and CONFIDENTIAL PATIENT HISTORY
1. Describe what has brought you to our office today: ______________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
When did symptoms begin: _______________________________ Last occurrence: ______________________________
Aggravation/relief factors_______________________________________/______________________________________
Are symptoms changing? Better/Worse? Does pain interfere with daily activities? ________________________________
On a scale of 0-10, 0 being no pain and 10 being worst, rate the severity of your condition: ________________________
2. This condition is the result of: Accident/Automobile Accident /On the Job Injury /Repetitive Usage /Other____________
3. Who else have you seen for this condition?
Provider Name
Phone
Diagnosis
Treatment
4. What medications are you currently taking, including over the counter drugs and vitamins?
Name of Drug
Dosage
Diagnosis
Date Started
5. Give EXACT DATES & results if possible. When was your last:
Physical examination:
____________________________
Blood test:
____________________________
Urinalysis:
____________________________
Chest x-ray:
____________________________
Spinal x-ray:
_________________________
Dental x-ray:
_________________________
6. What are your lifestyle habits?
Tobacco: (pack/day) _______ Alcohol: (drinks/day) _______ Sleep: (hours/day) _______ Waking up: (#/night) _______
Exercise/Hobbies___________________________________________________________________________________
Do you “pop” or “crack” your own spine? Yes/No how often? __________
7. Have you had any previous surgeries or hospitalizations?
Date
Diagnosis
Procedure
Provider
Signature: ____________________________________________ Date: ____________