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Patient Name: _____________________________________________________ Date: ____________________________
Please mark the areas where you have pain/Tenderness
Present Complaints
Please circle all that apply
1.
2.
3.
4.
5.
6.
7.
8.
Headache
Neck
Mid Back
Low Back
Hips
Legs
Arms
Other ________________________________
How long have you had these conditions? _________________________________________________________________
Are these conditions progressively getting worse? Yes No Constant
Have you received treatment for these conditions? Yes No (If Yes, with whom?) __________________________________
What makes your condition worse? _______________________________________________________________________
What makes your condition better? _______________________________________________________________________
Check the following conditions that apply to you, past or present. Please add your comments to clarify the condition.
Musculoskeletal
□ Headaches
□ Joint Stiffness/Swelling
□ Spasms/Cramps
□ Broken/Fracture Bones
□ Strains/Sprains
□ Back/Hip Pain
□ Shoulder, Neck, or Arm Pain
□ Leg, foot pain
□ Chest, Ribs, Abdominal Pain
□ Problems Walking
□ Jaw Pain/TMJ
□ Tendonitis
□ Bursitis
□ Arthritis
□ Osteoporosis
□ Scoliosis
□ Bone or Joint disease
□ Other: _____________________
Circulatory & Respiratory
□ Dizziness
□ Shortness of Breath
□ Fainting
□ Cold Feet or hands
□ Poor Circulation
□ Varicose Veins
□ Blood Clots
□ Stroke
□ Heart Condition
□ Allergies
□ High/Low Blood Pressure
Digestive
□ Nervous Stomach
□ Indigestion
□ Constipation
□ Intestinal Gas/Bloating
□ Diarrhea
□ Diverticulitis
□ Irritable Bowel Syndrome
□ Crohn’s Disease
□ Vomiting Blood
Nervous System
□ Numbness/Tingling
□ Fatigue
□ Chronic Pain
□ Sleep Disorders
□ Ulcers
□ Cerebral Palsy
□ Epilepsy
□ Multiple Sclerosis
□ Parkinson’s disease
□ Spinal Cord Injury
□ Other: _________________
Reproductive System
□ Pregnancy: □ Current
□ PMS
□ Menopause
□ Endometriosis
□ Hysterectomy
□ Prostate Problems
□ Hot Flashes
Other
□ Loss of Appetite
□ Depression
□ Hearing Impaired
□ Vision Impaired
□ Bladder Infection
□ Diabetes
□ Fibromyalgia
□ Cancer
□ Infectious Disease (Please List)
__________________________
Eye, Ear, Nose, Throat
□ Pain in Eyes
□ Ear Noises
□ Nose Bleeds
□ Sore Throat
□ Frequent Cough
Please List any Additional comments
Regarding Your Health:
______________________________
______________________________
______________________________
Females only: My signature on this form, I
do hereby state that I am not pregnant, nor
is pregnancy suspected at this time.
___________________________________
Patients Signature
_________________________________
Patients Name (Please Print)