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Download Lifting Postures: with Arms High Near from Knee Twist from Waist
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Total Wellness Chiropractic, PLLC Patient Health Record 5120 Telecom Dr Suite K Milan, TN 38358 731-686-8636 Confidential Today’s Date:____/_____/________ Personal Information Title: Mr. Ms. Mrs. Dr. Rev. Miss Prof. other: __________________________________ Last:__________________________ First:___________________________ Middle: ____________________________ Suffix: Jr Sr II III MD PhD DO Esq PA RN BSN other: _______________________ Address: ______________________________________________________________________________Apt # ______ City: __________________ State: ______ Zip: _________ Country: __________________ County: _____________ Home Phone: (_______) _______-_________ ext ______ Work Phone: (_______) _______-_________ ext ______ Cell Phone: (_______) _______-_________ ext ______ Birth Date: ____ /____/_______ Age:______ Fax #: (_______) _______-_________ ext ______ Sex: Male / Female Email Address: _____________________________ Spouses Name: __________________________________ Children (Names and Ages): __________________________________________________________________ Race: African American Asian Caucasian Hispanic Multiracial Native American Other: __________________ Marital Status: Single Married Widowed Divorced Separated Social Security #: _______-______-_______ How did you hear about us?_________________________________ Primary care physician’s name:________________________________________________________________ Name of any other physician(s) you have seen for current symptoms?_______________________________________ Our office is going to contact your primary care physician and any other physician(s) you have seen to relay to them your exam notes and our treatment plan. If you would not like us to contact them please let us know? ______ Emergency Contact Title: Miss Mrs. Ms. Master Mr. Dr. Prof. Rev. other: __________________________________ Last:__________________________ First:___________________________ Middle: ____________________________ Suffix: Jr Sr II III MD PhD DO Esq PA RN BSN other: __________________ Home Phone: (_______) _______-_________ ext ______ Work Phone: (_______) _______-_________ ext ______ Cell Phone: (_______) _______-_________ ext ______ Relationship: Spouse Relative Friend Other ______________________ Employment Information Business Name:_______________________________________Occupation__________________________________ Address: ______________________________________________________________________________Apt # ______ City: __________________ State: ______ Zip: _________ Country: __________________ County: _____________ Phone: (_______) _________-____________ Fax #: (_______) _________-____________ 1 Current Health Condition If you are here for wellness care please check this box: □ section below. and skip this section and go to review of systems PLEASE LABEL ON THE DIAGRAM THE AREA OF DISCOMFORT Use the letters BELOW to indicate the TYPE AND LOCATION of your sensations What is your chief complaint? (LIST only ONE complaint, below you will have the opportunity to list others):_________________________________ __________________________________________________________ Key: A=Ache B=Burning N = Numbness P=Pins & Needles S=Stabbing/Sharp When did this Condition BEGIN? ___/___/___________________________ List in your own words how you think your condition started __________ ________________________________________________________________ __________________________________________________________ Has it ever occurred before? Yes No. When? _______________ Is the Condition: Auto Related Job Related Home Injury Slip or Fall Lifting Slept Wrong Gradual Repetitive Other Explain: ______________________________________________ On a scale to 1-10, 10 being severe and 1 minimal how would you rate this symptom?___________ What percentage of the day do you experience the symptom (1-100%)? _____________________ Please list any other complaints (pains/symptoms) below? G or S 1-10 1-100% 1)__________________ When did it start?_________Gradual or Sudden_____Severity________Percentage of day_______ 2)__________________ When did it start?_________ Gradual or Sudden_____Severity________Percentage of day_______ 3)__________________ When did it start?_________Gradual or Sudden_____Severity________Percentage of day_______ 4)__________________ When did it start?_________Gradual or Sudden_____Severity________Percentage of day_______ 5)__________________ When did it start?_________Gradual or Sudden_____Severity________Percentage of day_______ Occupation/Job Title: _______________________________________________ Work: _____ hrs week Description of Work:______________________________________________________________________________ Job Classification: Sedentary (<5lbs) Light (5-20lbs) Lifting Frequency: Constant (67-100%/day) Lifting Postures: with Arms High Near Work Activity Postures: (hrs/day) bending: _____h/d climbing: _____h/d reaching: _____h/d sitting: _____h/d Repetitive Activities: (hrs/day) assembly/fine manipulation: _____h/d hand tool use: _____ h/d Moderate (20-50lbs) Frequent (33-66%/day) from Knee Twist kneeling: _____h/d standing: _____h/d Heavy (>50 lbs) Occasional (0-32%/day) from Waist pulling: _____h/d twisting: _____h/d computer use/typing: _____ h/d operation of machinery controls: _____ h/d pushing: _____h/d walking: _____h/d grasping: _____ h/d phone use: _____h/d 2 Condition’s Effect On Job Performance: No Effect Mild Painful (Can do) Mod Painful (limited ability) Mod/Sev Limited Duty Sev No Limited Duty Sev (can’t do limited duty) Daily Activities: Effects of Current Condition on Performance Bending: No Effect Mild Painful (Can do) Mod Painful (Limited) Sev Carrying: No Effect Mild Painful (Can do) Mod Painful (Limited) Sev Change Posn–Sit-Stand: No Effect Mild Painful (Can do) Mod Painful (Limited) Sev Climb Stairs: No Effect Mild Painful (Can do) Mod Painful (Limited) Sev Driving: No Effect Mild Painful (Can do) Mod Painful (Limited) Sev Extended Computer Use: No Effect Mild Painful (Can do) Mod Painful (Limited) Sev Feeding: No Effect Mild Painful (Can do) Mod Painful (Limited) Sev Household Chores: No Effect Mild Painful (Can do) Mod Painful (Limited) Sev Kneeling: No Effect Mild Painful (Can do) Mod Painful (Limited) Sev Lift Children: No Effect Mild Painful (Can do) Mod Painful (Limited) Sev Lifting: No Effect Mild Painful (Can do) Mod Painful (Limited) Sev Concentration: No Effect Mild Painful (Can do) Mod Painful (Limited) Sev Self Care–Bathing: No Effect Mild Painful (Can do) Mod Painful (Limited) Sev Self Care–Dressing: No Effect Mild Painful (Can do) Mod Painful (Limited) Sev Self Care–Shaving: No Effect Mild Painful (Can do) Mod Painful (Limited) Sev Sexual Activities: No Effect Mild Painful (Can do) Mod Painful (Limited) Sev Sleep: No Effect Mild Painful (Can do) Mod Painful (Limited) Sev Sitting: No Effect Mild Painful (Can do) Mod Painful (Limited) Sev Standing: No Effect Mild Painful (Can do) Mod Painful (Limited) Sev Walking: No Effect Mild Painful (Can do) Mod Painful (Limited) Sev Lying down: No Effect Mild Painful (Can do) Mod Painful (Limited) Sev Yard Work: No Effect Mild Painful (Can do) Mod Painful (Limited) Sev Unable to Perform Unable to Perform Unable to Perform Unable to Perform Unable to Perform Unable to Perform Unable to Perform Unable to Perform Unable to Perform Unable to Perform Unable to Perform Unable to Perform Unable to Perform Unable to Perform Unable to Perform Unable to Perform Unable to Perform Unable to Perform Unable to Perform Unable to Perform Unable to Perform Unable to Perform Recreational Activity: Effects of Current Condition on Performance ___________________ No Effect Mild Painful (Can do) Mod ___________________ No Effect Mild Painful (Can do) Mod ___________________ No Effect Mild Painful (Can do) Mod ___________________ No Effect Mild Painful (Can do) Mod Unable to Perform Unable to Perform Unable to Perform Unable to Perform Painful (limited) Painful (limited) Painful (limited) Painful (limited) Sev Sev Sev Sev REVIEW OF SYSTEMS -Below is a list of symptoms that may seem unrelated to the purpose of your appointment. However, these questions must be answered carefully as the problems can affect your overall course of care. I DENY having or have had any of the symptoms or problems listed below. Constitutional: chills daytime drowsiness blindness blurred vision cataracts change in vision double vision eye pain Ears, Nose and Throat: Respiration: night sweats weight gain weight loss I DENY having any of the symptoms or problems listed below. Eyes/Vision: bleeding dentures difficulty Swallowing discharge dizziness fatigue fever field cuts glaucoma itching photophobia tearing wear glasses/contacts I DENY having any of the symptoms or problems listed below. ear drainage ear pain fainting hearing loss history of head injury hoarseness frequent sore throats headaches loss of sense of smell nasal congestion nosebleeds postnasal drip rhinorrhea (runny nose) sinus infections snoring sore throat ringing in ears TMJ problems I DENY having any of the symptoms or problems listed below. asthma coughing up blood sputum production cough shortness of breath wheezing 3 Cardiovascular: I DENY having any of the symptoms or problems listed below. angina (chest pain or discomfort) high blood pressure chest pain claudication (leg pain/ache) heart murmur heart problems low blood pressure orthopnea (difficulty breathing lying down) palpitations paroxysmal nocturnal dyspnea (waking at night w/ shortness of breath) shortness of breath with exertion or exercise swelling of legs ulcers varicose veins Gastrointestinal: I DENY having any of the symptoms or problems listed below. abdominal pain belching black - tarry stools constipation diarrhea difficulty swallowing heartburn hemorrhoids indigestion jaundice nausea rectal bleeding abnormal stool color abnormal stool consistency vomiting blood vomiting Female: I DENY having any of the symptoms/problems and/or using any of the items listed below. birth control breast lumps/pain burning urination cramps frequent urination hormone therapy vaginal bleeding vaginal discharge I DENY having any of the symptoms or problems listed below. Male: burning urination erectile dysfunction frequent urination hesitancy/ dribbling prostate problems urine retention I DENY having any of the symptoms or problems listed below. Endocrine: cold intolerance diabetes excessive appetite Skin: irregular menstruation pregnancy urine retention excessive hunger excessive thirst abnormal frequency of urination goiter hair loss heat intolerance unusual hair growth voice changes I DENY having any of the symptoms or problems listed below. changes in nail texture changes in skin color hair growth hair loss hives history of skin disorders itching paresthesias rash skin lesions / ulcers varicosities Nervous System: I DENY having any of the symptoms or problems listed below. dizziness facial weakness limb weakness loss of consciousness numbness seizures slurred speech stress headache loss of memory sleep disturbance strokes Psychologic: tremor unsteadiness of gait/ loss of balance I DENY having any of the symptoms or problems listed below. obsessive compulsive disorder anxiety loss or change in appetite behavioral change bi-polar disorder confusion convulsions depression insomnia memory loss mood change Allergy: I DENY having any of the symptoms or problems listed below. anaphalaxis food intolerance Hematologic: itching acute nasal congestion chronic nasal congestion rash sneezing I DENY having any of the symptoms or problems listed below. anemia bleeding blood clotting blood transfusion bruising easily fatigue lymph node swelling PAST HEALTH HISTORY – Fill out carefully as these problems can affect your overall course of care. Previous Chiropractic Care: I have not previously seen a Chiropractor OR Fill in the information BELOW. Doctor’s Name: ________________________ Location: ______________________ Date of Last Visit: ___________ Were you satisfied with your care? Yes No. Why? _________________________________________________ For how long? _________________________ Approximately how many visits?_______________________ Current Medication (s): List ANY/ALL medications/supplements you are CURRENTLY taking. (More space on next page) Medication Dosage For What Condition? How long have you been taking this? 4 Do you believe that the childhood Illnesses listed below are contributory to your CURRENT Condition? yes or no. Childhood Illness (es): LIST all health conditions. CIRCLE all CURRENT conditions. ADD atopic dermatitis (eczema) allergies/hayfever anemia asthma bedwetting cerebral palsy chicken pox crohn’s/colitis depression diabetes ear infections fetal drug exposure food allergies (list below) headaches hepatitis HIV measles mumps psoriasis rash scoliosis seizure disorder sickle cell anemia spina bifida other: Do you believe that the Adult Illnesses listed below are contributory to your CURRENT Condition? yes or no. Adult Illness (es): LIST all past and previous health conditions. CIRCLE all CURRENT conditions. ADD alzheimers anemia arthritis asthma cancer cerebral palsy chicken pox crohn’s/colitis CRPS (RSD) CVA (stroke) Surgery (ies): cystic kidney disease depression diabetes (insulin dep) diabetes (non insulin) eczema emphysema eye problems fibromyalgia heart disease hepatitis HIV hypertension influenzal pneumonia liver disease lung disease lupus erythema (discoid) lupus erythema (systemic) multiple sclerosis parkinson’s disease unspecified pleural effusion pneumonia psoriasis psychiatric problems scoliosis seizures shingles past history of similar symptoms STD’s (unspecified) suicide attempt(s) thyroid problems vertigo other: LIST All Surgical Procedures. Write the DATE of the Procedure immediately afterward. angioplasty appendectomy caesarian section cardic catheterization carpal tunnel repair coronary artery bypass cosmetic D&C dental sugery gall bladder hemorrhoidectomy hernia repair hysterectomy joint reconstruction joint replacement knee repair laminectomy mastectomy pacemaker insertion rotator cuff spinal fusion tonsilectomy other: Females ONLY: Ob/Gyn Mark all that apply below. If you have been pregnant in the past, please fill in the appropriate information below. _____ Number of complicated pregnancies _____ Number of uncomplicated pregnancies _____Number of C-sections _____ Number of vaginal deliveries _____ Number of miscarriages _____ Number of terminated pregnancies I… am currently pregnant am NOT currently pregnant Menstrual History. I… currently have menses. My menses… are regular. _____ Age of first menses Date of last menses: ______/______/________ Injury (ies): back injury broken bones disability (ies) fall (severe) fracture currently DO NOT have menses. are NOT regular. _____ Age when menopause began Mark or List All Injuries. Write the DATE of the Injury immediately afterward. head injury (loss of consciousness) head injury (no loss of consciousness) industrial accident joint injury laceration (severe) motor vehicle accident soft tissue injury (mild) soft tissue injury (moderate) soft tissue injury (severe) other: 5 Family History: Mark all that apply below. List any specific conditions past or present after has/had: alive alive alive alive alive alive alive alive alive alive alive general family Father Mother paternal grandfather paternal grandmother maternal grandfather maternal grandmother son (s) daughter(s) brother(s) sister(s) Social History: deceased deceased deceased deceased deceased deceased deceased deceased deceased deceased deceased normally developed normally developed normally developed normally developed normally developed normally developed normally developed normally developed normally developed normally developed normally developed no significant disease no significant disease no significant disease no significant disease no significant disease no significant disease no significant disease no significant disease no significant disease no significant disease no significant disease has/had:______________________ has/had:______________________ has/had:______________________ has/had:______________________ has/had:______________________ has/had:______________________ has/had:______________________ has/had:______________________ has/had: _____________________ has/had: _____________________ has/had:______________________ Mark all that apply below. Alcohol: do not drink alcohol social consumption only drink the following regularly (mark below) beer liquor wine; quantity of ________ oz./glasses per day week month My Dietary Intake consists mainly of the following: (mark all that apply) high fat high salt low fiber high fiber low calorie low salt high protein low carbohydrate low sugar Tobacco: Do not use tobacco Do not smoke cigars, cigarettes or pipe Live with a smoker Quit smoking Smoke: # ____ per Day Week Month; Chew: #______cans per Day Week Year 1) Job Stress: None Moderate 2) Family Stress: None Moderate Severe Severe 3) How would you rate your overall health? On a scale of 1-10, 10 being great________________________________ 4) How would you rate your overall nutrition? On a scale of 1-10, 10 being great________________________________ 5) How would you rate your exercise? On a scale of 1-10, 10 being great________________________________ Insurance Information: Who Is Responsible For Your Bill? YOU and… (mark appropriate box(es)) Myself ONLY Spouse Health Insurance Worker’s Comp Auto Insurance Medicare Medicaid Other (be specific):_______________ Policy Holder’s Name: ____________________________________ Policy Holder’s DOB:___________________________ Policy Holder’s Social Security if other than yours#: _______ - _______ - ________ Auto / Personal Injury: Fill out only if you have been in an accident recently. Have you filed a report with your insurance? Yes No Carrier: _____________________________________________ Policy # _______________________________ Carriers Phone #: Adjuster: ______________________________ (_______) ___________-_______________ Claim #: _____________________________________________ Consent to treat: I hereby state that the information provided by me is accurate and whole. I hereby authorize the Doctor to treat my condition as he or she deems appropriate through the use of Chiropractic Health Care, and I give authority for these procedures to be performed. Patient Print Name: _____________________________ Patient’s Signature: __________________________ Date: ___________ Guardian or Spouse’s Signature of Authorizing Care: __________________________________ Date: ______________ 6
