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
PATIENT INFORMATION FORM ____________________________ TODAY’S DATE: NAME: ☐ MALE ☐FEMALE ADDRESS: CITY: DATE OF BIRTH: ☐MARRIED ☐DIVORCED AGE: ☐SINGLE ☐SEPARATED STATE: HOME PHONE: CELL: SOCIAL SECURITY #: DRIVER’S LICENSE: SPOUSE’S NAME: AGES OF CHILDREN: EMPLOYER/BUSINESS NAME: BUSINESS ADDRESS: BUSINESS PHONE: TYPE OF WORK: ☐WIDOWED ☐________ ZIP: FAX: STATE: EMAIL ADDRESS: OCCUPATION/JOB TITLE: HOW DID YOU HEAR ABOUT US? EMERGENCY CONTACT: PHONE #: INSURANCE ADDRESS: RELATIONSHIP: WHO IS RESPONSIBLE FOR YOUR BILL? ☐SELF ☐WORKER’S COMP ☐AUTO INSURANCE MEDICARE ☐MEDICAID ☐OTHER (BE SPECIFIC): PERSONAL HEALTH INSURANCE CARRIER: HEALTH ID CARD #: INSURED PERSON’S NAME: PRIMARY CARE PHYSICIAN: INSURED PERSON’S SOCIAL SECURITY #: PHARMACY: CURRENT HEALTH CONDITION CHIEF COMPLAINT: (WHY ARE YOU HERE TODAY?) PLEASE CIRCLE AREAS OF DISCOMFORT BODY AREA INVOLVED: ☐CERVICAL (NECK) ☐SPINE (MID-BACK), RIBS, PELVIS (LOW BACK) CONDITION: ☐NEW ☐RECURRING MECHANISM OF ONSET: ☐AUTO ☐FALL ☐OVER EXERTION ☐WORK ☐LIFTING ☐REPETITIVE MOTION SYMPTOMS: ☐PAIN ☐STIFFNESS ☐NUMBNESS ☐WEAKNESS LOCATION: ☐LEFT ☐BILATERAL ☐RIGHT QUALITY: ☐BURNING ☐DIFFUSE ☐DULL/ACHING ☐LOCALIZED ☐SHARP ☐SHOOTING ☐UPPER EXTREMITY (ARMS, WRIST, HANDS) ☐LOWER EXTREMITY (LEGS, FEET, TOES) ☐EXACERBATION ☐CHRONIC ☐UNKNOWN ☐SLIP OR FALL ☐OTHER ☐SLEPT WRONG ☐NO INJURY ☐STABBING ☐THROBBING ☐TIGHTNESS ☐TINGLING ☐RADIATING ☐OTHER ON A SCALE OF 0-10, (10 BEING THE WORST) RATE YOUR SYMPTOMS (RESTING): 0 1 2 3 4 5 6 7 8 9 10 ON A SCALE OF 0-10, (10 BEING THE WORST) RATE YOUR SYMPTOMS (WITH ACTIVITY): 0 1 2 3 4 5 6 7 8 9 10 DURATION: SYMPTOM(S) STARTED: SYMPTOM(S) WORSENED: SYMPTOM(S) LAST OCCURRED: SYMPTOM(S) LAST EPISODE: INJURY OCCURRED: ACCIDENT OCCURRED: TIMING WORSE IN THE: ☐MORNING ASSOCIATED SIGNS & SYMPTOMS: ☐BLURRED ☐VISION ☐DEPRESSION ☐DIZZINESS ☐ DULL ☐ SHARP QUALITY OF HEADACHES: OTHER ASSOC. SIGNS & SYMPTOMS: MODIFYING FACTORS – SYMPTOMS BETTER WITH: SINCE CONDITION BEGAN, HAS ANYTHING PERMANENTLY HELPED YOU? HAS ANYTHING THAT YOU HAVE DONE, THUS FAR, FIXED YOUR PROBLEM ☐ACHES ☐COLD LIMB ☐DIZZINESS ☐FATIGUE ☐ACTIVITY ☐BENDING ☐AFTERNOON ☐NIGHT ☐W/ACTIVITY ☐HEADACHES ☐IRRITABILITY/MOOD SWING ☐LOCALIZED TINGLING ☐THROBBING ☐STABBING ☐COLD ☐HEAT ☐AURA ☐NO AURA ☐FEVER ☐HEARTBURN ☐MUSCLE SPASM ☐NAUSEA ☐MASSAGE ☒MOVEMENT ☐CONSTANT ☐NAUSEA ☐RADIATING ☐RINGING IN EARS ☐RADIATION: ☐WEAKNESS: ☐NUMBNESS ☐PALE BLUISH SKIN ☐PANIC ☐PINS & NEEDLES ☐OTC MEDS ☐REST ☐RX MEDS ☐STRETCHING ☐LEFT ☐LEFT ☐RUNNY NOSE ☐STIFFNESS ☐SWEATING ☐SWELLING ☐SITTING ☐STANDING ☐ INTERMITTENT ☐SLEEP ☐DISTURBANCE ☐STIFFNESS ☐RIGHT ☐RIGHT ☐BILATERAL ☐BILATERAL ☐TINGLING ☐VOMITING ☐WEAKNESS ☐TWISTING ☐WALKING ☐NOTHING HELPS ☐YES ☐NO ☐YES ☐NO EMPLOYMENT OCCUPATION: JOB CLASSIFICATION: WORK (HRS/DAY): ☐SITTING ☐LIGHT ☐MODERATE ☐SITTING ☐STANDING REPETITIVE ACTIVITIES: (HRS/DAY) ☐COMPUTER ☐PHONE HOW DOES THIS CONDITION EFFECT JOB PERFORMANCE: WORK ACTIVITY POSTURES: (HRS/DAY) LIFTING ☐HEAVY ☐CONSTANT ☐FREQUENT ☐OCCASIONAL FREQUENCY: LIFTING (66-100% DAY) (33-65% DAY) (0-32% DAY) ☐WALKING ☐PUSHING ☐KNEELING ☐TWISTING ☐CLIMBING ☐PULLING ☐REACHING ☐BENDING ☐MACHINERY ☐ASSEMBLY ☐HAND TOOLS ☐GRASPING ☐MILD PAINFUL (CAN DO) ☐SEVERE (UNABLE TO PERFORM) ☐MODERATE PAINFUL (LIMITED) ☐OTHER (EXPLAIN) DAILY ACTIVITIES: ON A SCALE OF 0-10, TO WHAT LEVEL ARE YOU EXPERIENCING SYMPTOMS WHILE PERFORMING THESE ACTIVITIES ACTIVITY (CHECK APPLICABLE COLUMN) BENDING: 0 NO EFFECT 1 2 3 4 5 6 7 8 9 10 UNABLE TO DO CARE –INFIRM FAMILY: CARRYING GROCERIES: CHANGE POS.–SIT-STAND: CLIMB STAIRS: DRIVING: EXTENDED COMPUTER USE: FEEDING: HOUSEHOLD CHORES: KNEELING: LIFT CHILDREN: LIFTING: PET CARE: READING (CONCENTRATION): SELF CARE: SELF CARE–BATHING: SELF CARE–DRESSING: SELF CARE–SHAVING: SEXUAL ACTIVITIES: SLEEP: STATIC SITTING: STATIC STANDING: WALKING: YARD WORK: BELOW IS A LIST OF DISEASES 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. REVIEW OF SYMPTOMS – PLEASE FILL OUT ALL OF THE SECTIONS, EVEN IF “DENY” CONSTITUTIONAL: ☐CHILLS ☐WEIGHT GAIN ☐FATIGUE ☐DAYTIME SOMNOLENCE ☐I DENY ANY CONST. ISSUE(S) (DROWSINESS) ☐NIGHT SWEATS ☐WEIGHT LOSS ☐FEVER EYE/VISION: ☐I DENY ANY EYE/VISION ISSUE(S) ☐BLINDNESS ☐DOUBLE VISION ☐EYE PAIN ☐PHOTOPHOBIA EARS, NOSE, & THROAT: ☐I DENY ANY E/N/T ISSUE(S) ☐BLEEDING ☐DISCHARGE ☐DIZZINESS ☐SNORING RESPIRATION: ☐I DENY ANY RESPIRATORY ISSUE(S) CARDIOVASCULAR: ☐I DENY ANY CARDIO. ISSUE(S) ☐ASTHMA ☐FAINTING ☐HEADACHES ☐LOSS OF SMELL ☐SORE THROATS (FREQUENT) ☐COUGHING UP BLOOD GASTROINTESTINAL: ☐I DENY ANY GI ISSUE(S) ☐ABDOMINAL PAIN ☐BELCHING ☐BLACK, TARRY STOOLS ☐CONSTIPATION ☐ANGINA (CHEST PAIN OR DISCOMFORT) ☐CHEST PAIN ☐CLAUDICATION (LEG PAIN OR ACHINESS) ☐TEARING ☐BLURRED VISION ☐FIELD CUTS (VISUAL FIELD DEFECT) ☐NASAL CONGESTION ☐SINUS INFECTIONS ☐DENTAL IMPLANTS ☐SPUTUM PRODUCTION ☐EAR DRAINAGE ☐EAR INFECTION(S) ☐HEARING LOSS ☐TINNITUS (RIGHT IN EARS) ☐COUGH ☐HEART MURMUR ☐HEART PROBLEMS ☐ORTHOPNEA (DIFFICULTY BREATHING WHILE LYING DOWN) ☐DIARRHEA ☐DIFFICULTY SWALLOWING ☐HEARTBURN ☐HEMORRHOIDS ☐CATARACTS ☐GLAUCOMA ☐CHANGE IN VISION ☐ITCHING (AROUND EYES) ☐POST NASAL DRIP ☐DIFFICULTY SWALLOWING ☐EAR PAIN ☐SHORTNESS OF BREATH ☐WEAR GLASSES AND/OR ☐CONTACT LENSES ☐HOARSENESS ☐RHINORRHEA (RUNNY NOSE) ☐SINUS INFECTIONS ☐TMJ PROBLEMS ☐WHEEZING ☐PALPITATIONS (IRREGULAR ☐SWELLING OF LEGS OR FORCEFUL BREATHING OF ☐ULCERS THE HEART) ☐VARICOSE VEINS ☐PAROXYSMAL NOCTURNAL DYSPNEA (WAKING AT NIGHT WITH SHORTNESS OF BREATH) ☐INDIGESTION ☐ABNORMAL STOOL CALIBER ☐VOMITING (QUALITY) BLOOD ☐JAUNDICE ☐ABNORMAL STOOL COLOR ☐VOMITING (YELLOWING OF SKIN) ☐NAUSEA ☐ABNORMAL STOOL CONSISTENCY ☐RECTAL BLEEDING FEMALE: ☐I DENY ANY FEMALE ISSUE(S) MALE: ☐I DENY ANY MALE ISSUE(S) ☐BIRTH CONTROL THERAPY ☐BREAST LUMP/PAIN ☐BURNING URINATION ☐BURNING URINATION ☐PROSTATE PROBLEMS ☐CRAMPS ☐FREQUENT URINATION ☐HORMONE THERAPY ☐IRREGULAR MENSTRUATION ☐URINE RETENTION ☐VAGINAL BLEEDING ☐VAGINAL DISCHARGE ☐ERECTILE DYSFUNCTION ☐FREQUENT URINATION ☐URINATION RETENTION ☐HESITANCY/DRIBBLING ENDOCRINE: ☐I DENY ANY ENDOCRINE ISSUE(S) ☐COLD INTOLERANCE ☐DIABETES ☐EXCESSIVE APPETITE ☐EXCESSIVE HUNGER SKIN: ☐I DENY ANY SKIN ISSUE(S) ☐CHANGES IN NAIL TEXTURE ☐CHANGES IN SKIN COLOR NERVOUS SYSTEMS: ☐I DENY ANY NS ISSUE(S) ☐DIZZINESS ☐FACIAL WEAKNESS PSYCHOLOGICAL: ☐I DENY ANY PSYCHOLOGICAL ISSUE(S) ☐ANHEDONIA (INABILITY TO EXPERIENCE JOY OR ENJOY LIFE) ALLERGY: ☐I DENY ANY ALLERGY ISSUE(S) ☐ANAPHYLAXIS (HISTORY OF SNEEZING) HEMATOLOGY: ☐I DENY ANY HEMATOLOGY ISSUE(S) ☐ANEMIA ☐BLEEDING ☐EXCESSIVE THIRST ☐FREQUENT URINATION ☐HAIR GROWTH ☐HAIR LOSS ☐HEADACHES ☐LIMB WEAKNESS ☐ANXIETY ☐APPETITE CHANGES ☐HIVES ☐ITCHING ☐LOSS OF CONSCIOUSNESS ☐LOSS OF MEMORY ☐BEHAVIORAL CHANGE(S) ☐BIPOLAR DISORDER ☐FOOD INTOLERANCE ☐BLOOD CLOTTING ☐BLOOD TRANSFUSION(S) ☐GOITER ☐HAIR LOSS ☐PARESTHESIA (NUMBNESS, PRICKLING, OR TINGLING) ☐NUMBNESS ☐SEIZURES ☐HEAT INTOLERANCE ☐UNUSUAL HAIR GROWTH ☐RASH ☐HISTORY OF SKIN DISORDERS ☐SLEEP DISTURBANCE ☐STRESS ☐CONFUSION ☐CONVULSIONS ☐VOICE CHANGES ☐SKIN LESIONS /ULCERS ☐VARICOSITIES ☐STROKES ☐TREMORS ☐ UNSTEADINESS OF GAIT ☐DEPRESSION ☐INSOMNIA ☐MEMORY LOSS ☐MOOD CHANGES ☐ITCHING ☐NASAL CONGESTION ☐SNEEZING ☐BRUISES EASILY ☐FATIGUE ☐LYMPH NODE SWELLING PAST HEALTH HISTORY – PLEASE FILL OUT CAREFULLY AS THESE PROBLEMS CAN AFFECT YOUR OVERALL COURSE OF CARE. CHILDHOOD ILLNESS: ☐I DENY ANY CHILDHOOD ILLNESS(ES) ADULT ILLNESS:☐I DENY ANY ADULT ILLNESS(ES) SURGERIES:☐I DENY ANY SURGERY (IES) OB/GYN:☐I DENY ANY OB/GYN ISSUES INJURIES:☐I DENY ANY INJURY (IES) IMMUNIZATIONS: ☐I DENY ANY IMMUNIZATION(S) NON-DRUG ALLERGIES: ☐I DENY ANY NON-DRUG ALLERGIES ☐ADD ☐BED WETTING ☐DIABETES ☐FOOD ☐MEASLES ☐SEIZURE DISORDER ☐ALLERGIES/HAYFEVER ☐CEREBRAL ☐EAR INFECTIONS ALLERGIES ☐MUMPS ☐SICKLE CELL ANEMIA ☐HEADACHES PALSY ☐ASTHMA ☐FETAL DRUG ☐RASH ☐SPINA BIFIDA ☐CHICKEN POX ☐HEPATITIS ☐ATOPIC DERMATITIS ☐EXPOSURE ☐SCOLIOSIS ☐OTHER (PLEASE ☐DEPRESSION ☐HIV (ECZEMA) DESCRIBE) ☐ALZHEIMERS ☐CVA (STROKE) ☐FIBROMYALGIA ☐LUPUS ERYTHEMA ☐SEIZURE DISORDER (DISCOID) ☐ANEMIA ☐CYSTIC KIDNEY DISEASE ☐HEART DISEASE ☐SHINGLES ☐LUPUS ERYTHEMA ☐ARTHRITIS ☐DEPRESSION ☐HEPATITIS ☐STD’S (UNSPECIFIED) (SYSTEMIC) ☐ASTHMA ☐DIABETES (INSULIN) ☐HIV ☐SUICIDE ATTEMPT(S) ☐MULTIPLE SCLEROSIS ☐CANCER ☐DIABETES (NON INSULIN) ☐HYPERTENSION ☐THYROID PROBLEMS ☐PARKINSON’S DISEASE ☐CHICKEN BOX ☐EAR INFECTIONS ☐INFLUENZA ☐VERTIGO ☐PLEURISY (FREQUENT) PNEUMONIA ☐CHRON’S/COLITIS ☐PAST HISTORY OF ☐PNEUMONIA ☐EMPHYSEMA ☐LIVER DISEASE SIMILAR SYMPTOMS TO ☐CRPS (RSD) ☐PSYCHIATRIC PROBLEMS YOUR CURRENT ☐EYE PROBLEMS ☐LUNG DISEASE CONDITION ☐SCOLIOSIS ☐OTHER ____________________________________________________________________________________________________ ☐ANGIOPLASTY ☐CORONARY ARTERY ☐HEMORRHOIDECTOMY ☐LAMINECTOMY BYPASS ☐APPENDECTOMY ☐HERNIA REPAIR ☐MASTECTOMY ☐COSMETIC ☐CAESAREAN SECTION ☐HYSTERECTOMY ☐PACEMAKER ☐D & C INSERTION ☐CARDIAC ☐JOINT RECONSTRUCTION ☐DENTAL SURGERY ☐ROTATOR CUFF CATHETERIZATION ☐JOINT REPLACEMENT ☐CARPAL TUNNEL ☐GALL BLADDER ☐SPINAL FUSION REPAIR MENSTRUAL HISTORY: ☐I HAVE NEVER BEEN PREGNANT ☐MY MENSES IS REGULAR ☐I HAVE BEEN PREGNANT IN THE PAST ☐MY MENSES IS IRREGULAR AGE OF ONSET _____ ☐I AM CURRENTLY PREGNANT ☐I AM CURRENTLY IN MENOPAUSE ☐BACK INJURY ☐BROKEN BONES ☐SEVERE FALL ☐DTAP (DIPTHERIA, TETANUS & PERTUSSIS) ☐ANIMALS ☐TONSILLECTOMY ☐OTHER DATE OF LAST MENSES ___/___/___ ☐FRACTURE ☐INDUSTRIAL ACCIDENT ☐MOTOR VEHICLE ACCIDENT ☐DISABILITY ☐JOINT INJURY ☐MILD/MODERATE SOFT TISSUE INJURY ☐HEAD INJURY ☐SEVERE LACERATION ☐SEVERE SOFT TISSUE INJURY ☐FLU ☐HEPATITIS C ☐MMR (MEASLES, MUMPS, ☐SMALL POX ☐WHOPPING & RUBELLA) COUGH ☐HEPATITIS A ☐INFLUENZA ☐TB (PERTUSSIS) ☐PNEUMOCOCCAL ☐HEPATITIS B ☐IPV (POLIO) ☐VARIVAX (CHICKEN ☐PPD (MANTOUX TEST-TB) POX) ☐DAIRY ☐EGGS ☐FOOD COLORING ☐MOLD ☐POLLEN PREVIOUS TREATMENT ☐YES IF YES, WHO? (NAME) ☐NO ☐YES IF YES, WHO? (NAME) ☐NO PREVIOUS CHIROPRACTIC CARE? HAVE YOU SEEN OTHER DOCTORS FOR THIS CONDITION? WERE YOU SASTIFIED WITH THE RESULTS OF YOUR TREATMENT? ARE YOU CURRENTLY TAKING ANY PRESCRIPTION MEDICATIONS? DO YOU WEAR ANY OF THE FOLLOWING? ☐YES EXPLAIN: ☐NO ☐YES IF YES, PLEASE MARK OR LIST (BE SPECIFIC) ☐NO ☐HEAL LIFTS ☐INNER SOLES LOCATION OF OFFICE: ☐ALLERGY MEDICATION ☐ANTI-DEPRESSANTS ___ MOTHER ___ PATERNAL GRANDFATHER NAME ☐BLOOD ☐MUSCLE ☐PAIN KILLERS PRESSURE MEDS. RELAXERS ☐OTHER (PLEASE ☐INSULIN ☐NERVE PILLS SPECIFY) PLEASE LIST ANY OTHER CONDITIONS YOU FEEL WE SHOULD KNOW ABOUT – EVEN IF UNRELATED ☐ARCH SUPPORTS ☐ORTHOTICS FAMILY HISTORY – ENTER INITIALS BELOW: ___ GENERAL FAMILY ___ FATHER ___ PATERNAL GRANDMOTHER ___ MATERNAL GRANDFATHER TYPE OF TREATMENT: A = ALIVE D = DECEASED ___ MATERNAL GRANDMOTHER ___ SON(S) RELATION ___ DAUGHTER(S) ___ BROTHER(S) ___ SISTER(S) PAST & PRESENT HEALTH PROBLEMS SOCIAL HISTORY ALCOHOL: DRUGS: OZ.’S # GLASSES ☐NEVER ☐SOCIAL ☐BEER CONSUMPTION ☐LIQOUR ☐DAILY ONLY ☐WEEKLY ☐WINE ☐MONTHLY ☐ DENY ANY ILLEGAL DRUG USE ☐ HAVE NOT USED DRUGS SINCE _____ ☐ DENY USE OF IV DRUGS ☐ HAVE USED DRUGS FOR _____ ☐HIGH FAT ☐HIGH FIBER ☐HIGH PROTEIN ☐HIGH SALT ☐ DENY TOBACCO USE ☐ LIVE W/A SMOKER ☐ QUIT SMOKING DIET: MARK ALL THAT APPLY TOBACCO: ☐ LOW CALORIE ☐ LOW CARB ☐ LOW SUGAR # PER: ___ ☐ DAY ☐ WEEK ☐ MONTH ☐ LOW FIBER ☐ LOW SALT ☐ # CHEW ____ PLEAE READ CAREFULLY AND SIGN BELOW I understand and agree that health and accident insurance policies are an agreement between an insurance carrier and myself. Furthermore, I understand that chiropractic clinic will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to chiropractic clinic will be credited to my account upon receipt. However I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care or treatment, any fees for professional services rendered me will be immediately due and payable. I agree that I am responsible for all bills incurred at this office. 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. GUARDIAN OR SPOUSE’S SIGNATURE OF AUTHORIZING CARE: DATE: (SIGNATURE INDICATES CONSENT TO TREAT) PATIENT (PRINT NAME): PATIENT’S SIGNATURE: DATE: