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The Chiropractic Health & Wellness Center of Dayton, Inc.
Revised 03/2007
PATIENT HISTORY FORM-CONFIDENTIAL
Name:
Date:
Past Medical History (check all that currently or previously apply to you personally):
System Review:
High blood pressure
Skin Cancer or Lesions
Stomach Ulcers
Heart Attack
Lymphoma
Lung Disease / COPD
Diabetes - Type I or Type II (Circle)
Leukemia
Liver Disease(specify)______________
Headaches (specify)
Prostatitis / Elevated PSA
Kidney Disease(specify)____________
Cancer (specify) _______________
Endometriosis
Hyperthyroid
Stroke / TIA
Sleep Apnea
Hypothyroid
Asthma
Anxiety / Depression (please circle)
Pacemaker / Arterial Stent(s)
Allergies(specify)____________
Autoimmune / Inherited Condition (Ex. Blood Disorders, Polio, Chron’s Disease, IBS, Paget’s disease)
If yes, please list:
List All Family History:
(Office use only)
Musculoskeletal Review:
Gout
Lupus
Osteoporosis
Fibromyalgia
Arthritis
Reiter’s Syndrome
Scoliosis
Reynaud’s
Psoriasis / Psoriatic Arthritis
TMJ / Bruxism
Disc Degeneration
(Jaw clenching)
Bone Spurs
Double Vision
Rheumatoid Arthritis
Weakness
Ankylosing Spondylitis
Medical / Artificial Implants / Previous Bone Fractures
If yes, please list:
Neuropathy
Peripheral Circulatory Problems
Swelling of the hands or feet (specify)
Coldness of the hands or feet (specify)
Foot Drop / Weakness
Dizziness / Vertigo
Facial Numbness or Pain
Multiple Sclerosis
Other:
Recent steroid injections / current corticosteroid prescription
Please indicate if you use the following substances:
Tobacco
Never
Rarely
Alcohol
Never
Rarely
Recreational Drugs
Never
Rarely
Caffeine / Carbonated soda
Never
Rarely
Daily
Daily
Daily
Daily
(amount)
(amount)
(amount)
(ounces per day)
Diet Soda
Please list all previous trauma / auto accidents / surgeries & hospitalizations with dates and treatment:
Please list all current medications / dietary supplements / all routine exercise & physical activities:
Do you have Hepatitis B / Hepatitis C / Tuberculosis or HIV infection (Circle any that apply)
What is your dominant Hand (please circle):
R / L
Are you pregnant? YES / NO
# Of children and their respective ages:
What is your current stress level (1(no stress) – 10(intolerable stress))