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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
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?________________ 1 Family Health Information Relationship Past and Present Health Problems ____________________ ___________________________________________________________ ____________________ ___________________________________________________________ ____________________ ___________________________________________________________ ____________________ ___________________________________________________________ Prescription Medications Name of Drug Reason for Use For How Long? ___________________ _______________________________________ _____________ ___________________ _______________________________________ _____________ ___________________ _______________________________________ _____________ ___________________ _______________________________________ _____________ ___________________ _______________________________________ _____________ 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_______________________________________________________ _____________________________________________________________________________________ 2 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) 9 10 (high) Please Rate Your Current Energy Level From 1 - 10 (low) 1 2 3 4 5 6 7 8 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?______________ 3 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) 4 ____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. 5 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___________________ 6