Have you ever had any SPINAL surgeries? Yes___ No___



Confidential Patient Health Record Haley Chiropractic CenterPatient Name: ________________________________________________Date: ___________________SYMPTOMS BEGAN ON: ______/______/______WHERE IS YOUR PAIN? ____________________________________________________________________WHAT CAUSED YOUR PAIN? _________________________________________________________________________________________________________________________________________________________RATE YOUR LEVEL OF PAIN, 0 = NO PAIN - 10 = EXCRUCIATING PAINHeadache ______ Neck ______ Shoulders ______ Mid Back ______ Low back ______ Hips ______ Legs_____ Knees______ Other__________________________________ How often does the pain bother you? __Constantly (76%-100% of the time) __Frequently (51%-75% of the time) __Occasionally (26%-50% of the time) __Intermittently (%- 25% of the time)How much have your pain interfered with your usual daily activities? __Mild __Mild to moderate __Moderate __Moderately severe __SeverePlease complete the following:Height _________ Weight _________ Blood Pressure ___________Smoking: Everyday ____ Former____ Never ____Do you prefer traditional chiropractic adjustments? _____Do you prefer low force instrument adjustments? _____MARK WITH AN X WHERE THE PAIN IS.156210151130 Have you ever had any SPINAL surgeries? Yes___ No___ Location of the spinal surgery_________________________________________________Please list all other surgeries__________________________________________________Are you a stomach sleeper? Yes__No__Name: ___________________Date_________Pain Types: __Achy __Burning __Dull __Excruciating __Numb ache type __ Pounding __Sharp __Stabbing __Shooting __ Stinging __ThrobbingCheck all situations that aggravate your pain:__Coughing __Sneezing __Arising from a chair __Bending__Breathing __Looking down __Looking up __Repetitious movements __Sleeping__Turning the head left __Turning the head right __Flashing lights__Carrying __Climbing stairs __Driving __ Exercising __ Getting out of bed__Getting in & out of the car __Lifting __Pulling __Pushing __Reclining__Sitting __Standing __Stooping __Walking __Emotional upset __ StressDoes anything relieve your pain? No _____ Yes, Please list_____________________________________________Have you been told you have arthritis of the spine or disc degeneration? __Yes __NoName of Doctor that diagnosed the arthritis/disc degeneration: __________________________________PLEASE LIST ANY MEDICATIONS (OVER THE COUNTER OR PRESCRIPTION) YOU ARE CURRENTLY TAKING FOR THE CONDITION YOU ARE HERE FOR TODAY. ______________________________________________________________________________________REVIEW OF SYSTEMS: PLEASE MARK IF YOU HAVE ANY OF THE FOLLOWING ISSUES:MUSCULOSKELETALback injuries____back pain____frequent foot cramps____general muscle tension____heel spurs____hot joints____joint pain____joint swelling____leg cramps during the day____leg cramps in bed or at rest____muscle cramps____muscle pain____muscle tenderness____muscle weakness____muscle twitching____neck injuries____neck pain____osteoarthritis____pain between the shoulders____painful feet____shoulder/arm pain____spinal curvature (scoliosis)____tender ribs____tenderness over a bone____Date: ____________________________Patient Name: First ____________________ Middle Initial____ Last ____________________________Address: ______________________________________________________________________________ City: _________________________________________________________________________________State: ________ Zip: ____________Birth date: _____/_____/_________ Age: ____ Cell Phone Number: ____________________________Home Phone Number: ___________________________Email address: ___________________________________________________________________________(By providing your email address, you are giving your permission to be contacted via email. Contact can include newsletters, appointment reminders, or other information. We will never send HIPAA protected information to you via email. We will never share or sell your email address.)Gender: Male/Female __Single __Married __Widowed __Divorced Spouses Name: _______________________________________________ # of Children: _____ Name of Insurance Company: ____________________________________________________________________Employer: _____________________________________________________________________________________ Referred by: ___________________________________________________________________________________NECK PAIN SCALEThis questionnaire will give your provider information about how your neck condition affects your everyday life. Please answer every section by marking the one statement that applies to you. If two or more statements in one section apply, please mark the one statement that most closely describes you.NAME:____________________________PAIN INTENSITY __A. No pain at the moment.__B. Mild Pain at the moment.__C. Moderate pain at the moment.__D. Fairly severe pain at the moment.__E. Very severe pain at the moment.__F. Worst imaginable pain at the moment.PERSONAL CARE__A. Personal care is normal without pain.__B. Personal care normal with extra pain.__C. Personal care painful/slow and careful.__D. Manage most personal care with some help.__E. Needs help everyday in most aspects of care.__F. Difficulty dressing and washing/stays in bed.LIFTING__A. Lifts heavy weights with no pain.__B. Lifts heavy weights with pain.__C. Can lift heavy weights from a table.__D. Can lift light weights from a table.__E. Can lift only very light weights.__F. Cannot lift or carry anything.READING__A. No pain while reading.__B. Slight pain while reading.__C. Moderate pain while reading.__D. Moderate pain prevents reading.__E. Severe pain prevents reading.__F. Cannot read at all.HEADACHES__A. No headaches.__B. Slight, infrequent headaches.__C. Moderate, infrequent headaches.__D. Moderate, frequent headaches.__E. Severe, infrequent headaches.__F. Constant headaches.DATE:___________________CONCENTRATION __A. Can concentrate without difficulty.__B. Can concentrate with slight difficulty.__C. Can concentrate with fair difficulty.__D. Can concentrate with a lot of difficulty.__E. Can concentrate with extreme difficulty.__F. Cannot concentrate at all.WORK__A. Work is unrestricted.__B. Can do usual work but no more.__C. Can do most usual work, but no more.__D. Cannot do usual work.__E. Can hardly do any work.__F. Cannot do any work.DRIVING__A. Can drive without pain.__B. Driving causes slight neck pain.__C. Driving causes moderate neck pain.__D. Cannot drive long due to moderate pain.__E. Can hardly drive due to severe pain.__F. Pain prevents driving.SLEEPING__A. No difficulties sleeping.__B. Sleep is mildly disturbed.__C. 1-2 hours loss of sleep.__D. 2-3 hours loss of sleep.__E. 3-5 hours loss of sleep.__F. 5-7 hours loss of sleep.RECREATION__A. Recreation is not affected.__B. Some neck pain, but does not affect activity.__C. Some activity is affected by pain.__D. Most activity is affected by pain.__E. Activity severely restricted by pain.__F. Cannot do any activity. Back Pain ScaleThis questionnaire will give your provider information about how your back condition affects your everyday life. Please answer every section by marking the one statement that applies to you. If two or more statements in one section apply, please mark the one statement that most closely describes your problem.Name ______________________________ Date______________________Section 1 – Pain IntensityPain comes and goes and is mild.Pain is mild and does not vary.Pain comes and goes and is moderate.Pain is moderate and does not vary much.Pain comes and goes and is severe.Pain is severe and does not vary much.Section 2 – Personal CareDoes not change habits to avoid pain.Does not change habits/some pain.Does not change habits/increases pain.Changes habits/increases pain.Unable to do some personal care without help.Unable to wash or dress without help.Section 3 – LiftingLifts heavy weights with no pain.Lifts heavy weights with pain.Cannot lift heavy weights off the floor.Can lift heavy weights from a table.Can lift light weights from a table.Can lift only very light weights.Section 4 – WalkingPain does not prevent walking.Cannot walk more than one mile.Cannot walk more than ? mile.Cannot walk more than ? mile.Can walk only with crutches.Bedridden and must crawl to the toilet.Section 5 – SittingCan sit in any chair as long as desired.Can sit only in the favorite chair as long as desired.Can sit no more than 1 hour. Can sit not more than ? hour.Can sit no more than 10 minutes.Cannot sit at all due to pain.Section 6 – StandingCan stand for an unlimited time without pain.Some pain standing/doesn’t increase with time.Cannot stand for more than 1 hour.Cannot stand for more than ? hour.Cannot stand for more than 10 minutesCannot stand at all.Section 7 – SleepingNo pain in bed.Gets pain in bed, but sleeps well.Normal sleep reduced by ?.Normal night’s sleep reduced by ?.Normal night’s sleep reduced by ?.Cannot sleep at all due to pain.Section 8 – TravelingTravel without pain.Travel causes some pain, but not made worse.Causes extra pain/No change in form.Causes pain/Uses alternate travel.Pain restricts all forms of travel.Pain restricts travel except lying down.Section 9 – Social Normal and causes no pain.Normal but causes extra pain.Limits energetic interests.Pain limits/doesn’t go out as often.Pain restricted social life to home.Pain restricts all social life.Section 10 – Changing Degree of PainPain is rapidly improving.Pain fluctuates but is improving.Improvement is slow.Pain level is unchanged.Pain is gradually worsening.Pain is rapidly worsening.\s ................
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