Download About Your Health - Dr. Jane Torrie, DC Chiropractor

Dr. Jane Torrie, Chiropractor
Name_________________________________________________
Date_______________________________
Street Address______________________________________________________________________________________
City ___________________________ State_______ Zip___________ Email Address _____________________________
H. Phone _______________________ Cell Phone_____________________ Date of Birth___________ Age__________
Referred by________________________ Occupation______________________ Employer_______________________
Marital Status S
M
D
W
Spouse Name_______________________________________
Number of Children/Ages_________________________ Spouse’s Occupation__________________________________
Have you ever received Chiropractic Care?
Yes
No
_______________________________________
Are you using insurance? _________________________ Through employer?
Y
N
About Your Health
The human body is designed to be healthy. Throughout life, events occur that can damage your health expression. This
case history may help uncover layers of damage, especially to your nervous system and spine, which can result in poor
health. Following your assessment, I will outline a course of care to begin to correct these layers of damage and to help
you recover your inborn/innate health potential.
Loss of Wellness
Please circle for each of the following:
Patient Comment
Chiropractor’s Comments
1. Health history:
Childhood illnesses?
Ear infections/ Colic/ Asthma?
Attention Deficit?
Accidents?
Surgery?
Did you fall down stairs?
Chair pulled out when sat down?
Were you yanked by your arm?
Did you have other traumas?
Did you ever break any bones?
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
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2. Current Health Habits:
Did/do you smoke?
Did/do you drink alcohol?
Did/do you use caffeine?
Y
Y
Y
N _______________
N _______________
N _______________
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Patient History Form
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Dr. Jane Torrie, Chiropractor
Diet, do you eat healthy foods?
Y N _______________
How much water do you drink?
_______________
Have you been in accidents/trauma? Y N _______________
Have you had surgery?
Y N _______________
Teeth problems?
Y N _______________
Eye problems?
Y N _______________
Hearing problems?
Y N _______________
Exercise regularly?
Y N _______________
Do you sleep well?
Y N _______________
Did/do you have occupational stress? Y N _______________
Physical stress?
Y N _______________
Emotional/Mental stress?
Y N _______________
Hobbies/Sports injuries?
Y N _______________
Sleeping posture? O side O stomach O back _______________
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Symptoms and Present State of Health
Previous years of unnoticed and or unattended damage to the nervous system and spine may show up as acute or
chronic symptoms.
Present Complaint/Reason for Seeking Care in this Office:
__________________________________________________________________________________________
Pain or Problem started on____________________________________________________________________
Pains are:
O Sharp
O Dull/ Ache O Constant
O Intermittent O Other_________________
Does this pain shoot, radiate, or travel in your body? ___ yes ____ no
Where?____________________________________________________
Are you experiencing numbness or tingling in any area of your body? ? ___ yes ____ no
Where?______________________________________
What activities aggravate your condition or pain?
_________________________________________________________________________________________
___________________________________________________________________________________________
What activities lessen your condition or pain?
_________________________________________________________________________________________
___________________________________________________________________________________________
Is this condition worse during certain times of the day?_______________________________________________
Is this condition interfering with work?______ Sleep?_ ____ Routine?_______ Other?____________________
Is this condition progressively getting worse? ____________________________________________________
Please Circle how you feel today:
(No Complaint/Pain) 0 1 2 3 4 5 6 7 8 9 10 (Worst Possible Complaint/Pain)
Other Doctors seen for this condition ____________________________________________________________
Any home remedies? _________________________________________________________________________
Please mark any of the following that you have now or have experienced:
Other Symptoms:
Patient History Form
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Dr. Jane Torrie, Chiropractor
O Headaches
O Neck Pain
O Sleeping Problems
O Low Back Pain
O Nervousness
O Tension
O Irritability
O Dizziness
O Pain between Shoulders
O Neck Stiff
O Joint Swelling
O Fever
O Loss of Balance
O Pain in Hands or Arms
O Numbness in Hands or Arms
O Pain in Legs or Feet
O Numbness in Legs or Feet
O Fatigue
O Depression
O Lights Bother Eyes
O Loss of Memory
O Shoulder Pain
O Sinus
O Shortness of Breath
O Asthma
O Allergies
O Chest Pains
O Heart Attack
O High Blood Pressure
O Stroke
O Cancer
O Painful Urination
O Diabetes
O Diarrhea
O Constipation
O Stomach Upset
O Menstrual Cramps
O Weight Loss
O Loss of Smell or Taste
What other conditions do you have? ________________________ __________________________________
Have you been under drug and medical care?________________________ __________________________________
What Medications are you taking?__________________________ __________________________________________
How long?_________________
Have you had surgery?_________________ What?_________________ When?_________________
Have you experienced side effects from the drugs and surgery? _________________________________________
_____________________________________________________________________________________________
Females Only – Date last Menstrual Period began on_________________ Are you possibly Pregnant?___________
Male only – Prostate issues ______________________________________________________________________
Is there a family History of:
Heart Disease
Arthritis
Cancer
Diabetes
Other__________________
Father’s side O
O
O
O
O ____________________
Mother’s side O
O
O
O
O ____________________
About Your Care
Chiropractic patients often experience several stages of treatment. The first is initial intensive care, which corrects the
most recent layer of spinal and neurological damage. This care often reduces or eliminates the symptoms. Then
reconstructive care begins, which corrects the years of damage that occurred when there were few symptoms. Finally,
Chiropractic offers a genuine approach to Wellness Care. If you have questions about any of these options please ask.
Then you’ll be able to begin a course of care that fits your goals.
I have read the above information and certify it to be true and correct to the best of my knowledge, and hereby
authorize this office of Chiropractic to do whatever is necessary in accordance with this state’s statues, to provide me
with chiropractic care.
I understand that I am financially responsible for all charges for services and agree to make payment and provide
insurance information when appropriate.
Signature______________________________________________________
Patient or Guardian
Patient History Form
__________________________
Date
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