Microsoft Word - patient_information.doc
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 Neuropathy
Osteoporosis Fibromyalgia Peripheral Circulatory Problems
Arthritis Reiter’s Syndrome Swelling of the hands or feet (specify)
Scoliosis Reynaud’s Coldness of the hands or feet (specify)
Psoriasis / Psoriatic Arthritis TMJ / Bruxism Foot Drop / Weakness
Disc Degeneration (Jaw clenching) Dizziness / Vertigo
Bone Spurs Double Vision Facial Numbness or Pain
Rheumatoid Arthritis Weakness Multiple Sclerosis
Ankylosing Spondylitis Other:
Medical / Artificial Implants / Previous Bone Fractures
If yes, please list:
Recent steroid injections / current corticosteroid prescription
Please indicate if you use the following substances:
Tobacco Never Rarely Daily (amount)
Alcohol Never Rarely Daily (amount)
Recreational Drugs Never Rarely Daily (amount)
Caffeine / Carbonated soda Never Rarely Daily (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))
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