Confidential Patient Health Record

How did you hear about us? *

Family
Friend
Co-Worker
Close to home/work
Dr.
Yellow pages
Drove by
Hospital
Insurance Plan

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Personal Information

Title *

Mr.
Ms.
Mrs.

Name *

First

Middle

Last

Suffix

Birth Date *

Age *

Sex *

Male
Female

Marital Status *

Single
Married
Widowed
Divorced
Separated

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Primary Phone Number *

Email Address

Social Security # *

Spouses Name

Children (Names and Ages)

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Emergency Contact

Name *

First

Middle

Last

Relationship *

Spouse
Relative
Friend
Other

Primary Phone Number *

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Employment Information

Business Name

Phone

Employer’s Email Address

Occupation/Job Title

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Current Health Condition

Unwanted Condition (Why you are here today?)

When did this Condition BEGIN?

Has it ever occurred before?

When ?

Is the Condition

Auto Related
Job Related
Home Injury
Slip or Fall
Lifting
Slept Wrong
Unknown Cause
Other

Explain

Date and Time of Accident

Date

Time

Condition/Pain STARTED on what Date

Do you SUFFER with ANY OTHER Condition than which you are now consulting us?

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REVIEW OF SYSTEMS

Below is a list of symptoms 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. Please check all that apply

Constitutional *

N/A
chills
fatigue
night sweats
weight loss
daytime drowsiness
fever
weight gain

Eyes/Vision *

N/A
blindness
change in vision
field cuts
photophobia
blurred vision
double vision
glaucoma
tearing
cataracts
eye pain
itching
wear glasses/contacts

Ears, Nose and Throat *

N/A
bleeding
ear drainage
hearing loss
nosebleeds
sore throat
dentures
ear pain
history of head injury
postnasal drip
tinnitus (ringing in ears)
difficulty swallowing
fainting
hoarseness
rhinorrhea (runny nose)
TMJ problems
discharge
frequent sore throats
loss of sense of smell
sinus infections
dizziness
headaches
nasal congestion
snoring

Respiration *

N/A
asthma
coughing up blood
sputum production
cough
shortness of breath
wheezing

Cardiovascular *

N/A
angina (chest pain or discomfort)
high blood pressure
shortness of breath with exertion or exercise
chest pain
low blood pressure
swelling of legs
claudication (leg pain/ache)
orthopnea (difficulty breathing lying down)
ulcers
heart murmur
palpitations
varicose veins
heart problems
paroxysmal nocturnal dyspnea (waking at night w/ shortness of breath)
varicose veins

Gastrointestinal *

N/A
abdominal pain
diarrhea
indigestion
abnormal stool caliber
vomiting blood
belching
difficulty swallowing
jaundice
abnormal stool color
black - tarry stools
heartburn
nausea
abnormal stool consistency
constipation
hemorrhoids
rectal bleeding
vomiting

Female *

N/A
birth control
cramps
irregular menstruation
vaginal bleeding
breast lumps/pain
frequent urination
pregnancy
vaginal discharge
burning urination
hormone therapy
urine retention

Male *

N/A
burning urination
frequent urination
prostate problems
erectile dysfunction
hesitancy/ dribbling
urine retention

Endocrine *

N/A
cold intolerance
excessive hunger
goiter
unusual hair growth
diabetes
excessive thirst
hair loss
voice changes
excessive appetite
abnormal frequency of urination
heat intolerance

Skin *

N/A
changes in nail texture
hair loss
itching
skin lesions / ulcers
changes in skin color
hives
paresthesias
varicosities
hair growth
history of skin disorders
rash

Nervous System *

N/A
dizziness
limb weakness
numbness
slurred speech
tremor
facial weakness
loss of consciousness
seizures
stress
unsteadiness of gait/
loss of balance
headache
loss of memory
sleep disturbance
strokes

Psychologic *

N/A
anhedonia
behavioral change
convulsions
memory loss
anxiety
bi-polar disorder
depression
mood change
loss or change in appetite
confusion
insomnia

Allergy *

N/A
anaphalaxis
itching
chronic nasal congestion
sneezing
food intolerance
acute nasal congestion
rash

Hematologic *

N/A
anemia
blood clotting
bruising easily
lymph node swelling
bleeding
blood transfusion
fatigue

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PAST HEALTH HISTORY

Fill out carefully as these problems can affect your overall course of care.

Previous Care for Same Condition

I have not seen a doctor for this condition OR Fill in the information BELOW

Have you seen other doctors for THIS CONDITION?

Who? (Doctor's Name)

Type of Treatment

Was the treatment beneficial in resolving condition?

Explain

Current Medication (s): List ANY/ALL medications you are CURRENTLY taking. Be Specific.

Childhood Illness (es): LIST all health conditions. CHECK all CURRENT conditions.

ADD
chicken pox
headaches
scoliosis
atopic dermatitis (eczema)
crohn’s/colitis
hepatitis
seizure disorder
allergies/hayfever
depression
HIV
sickle cell anemia
anemia
diabetes
measles
spina bifida
asthma
ear infections
mumps
bedwetting
fetal drug exposure
psoriasis
cerebral palsy
food allergies (list below)
rash
other

Adult Illness(es): LIST all health conditions. CHECK all CURRENT conditions.

ADD
cystic kidney disease
hypertension
psychiatric problems
alzheimers
depression
influenzal pneumonia
scoliosis
anemia
diabetes (insulin dep)
liver disease
seizures
arthritis
diabetes (non insulin)
lung disease
shingles
asthma
eczema
lupus erythema (discoid)
past history of similar symptoms
cancer
emphysema
lupus erythema (systemic)
STD’s (unspecified)
cerebral palsy
eye problems
multiple sclerosis
suicide attempt(s)
chicken pox
fibromyalgia
parkinson’s disease
thyroid problems
crohn’s/colitis
heart disease
unspecified pleural effusion
vertigo
CRPS (RSD)
hepatitis
pneumonia
CVA (stroke)
HIV
psoriasis
other:

Are any of these conditions current? If so, please list

Doctor: Are Child/Adult Illnesses listed contributory to the CURRENT Condition?

Surgery (ies): LIST All Surgical Procedures. Write the DATE of the Procedure immediately afterward.

angioplasty
cosmetic
hysterectomy
pacemaker insertion
appendectomy
D & C
joint reconstruction
rotator cuff
caesarian section
dental surgery
joint replacement
spinal fusion
cardiac catheterization
gall bladder
knee repair
tonsilectomy
carpal tunnel repair
hemorrhoidectomy
laminectomy
coronary artery bypass
hernia repair
mastectomy
other:

Please list the surgery and date of procedure

Injury (ies): Mark or List All Injuries. Write the DATE of the Injury immediately afterward.

back injury
head injury (loss of consciousness)
motor vehicle accident
broken bones
head injury (no loss of consciousness)
soft tissue injury (mild)
disability (ies)
industrial accident
soft tissue injury (moderate)
fall (severe)
joint injury
soft tissue injury (severe)
fracture
laceration (severe)
other:

Date of Injury if Applicable

Family History: Mark all that apply below. List any specific conditions past or present after has/had:

father

alive
deceased
normally developed
no significant disease
has/had a noteable illness/condition

Please list the condition your father had or has if applicable

mother

alive
deceased
normally developed
no significant disease
has/had a noteable illness/condition

Please list the condition your mother had or has if applicable

paternal grandfather

alive
deceased
normally developed
no significant disease
has/had a noteable condition

paternal grandmother

alive
deceased
normally developed
no significant disease
has/had a noteable condition

maternal grandfather

alive
deceased
normally developed
no significant disease
has/had a noteable condition

maternal grandmother

alive
deceased
normally developed
no significant disease
has/had a noteable condition

child (ren)

alive
deceased
normally developed
no significant disease
has/had a noteable condition

Please list the condition your child has or had if applicable

sibling

alive
deceased
normally developed
no significant disease
has/had a noteable condition

Please list the condition your brother or sister has/had if applicable

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Social History

Alcohol (do you drink?)

Never
Social Consumption only
Beer
Liquor
Wine

Diet (please mark all that apply)

High Fat
High Fiber
High Protein
High Salt
Low Calorie
Low Carb
Low Fiber
Low Salt
Low Sugar

Education (please mark the highest level completed):

Middle
Junior High
Votech
In High School
Did Not Finish High School
High School Diploma
Post High School Classes
Assoc/Technical Degree
In College
College Degree
In Graduate School
Graduate Degree
Doctorate
Other

Drugs

I do not use illegal drugs
I use drugs recreationally

Tobacco

Do NOT smoke cigars, cigarettes or pipe
Live with a smoker
Quit smoking
Smoke

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Insurance Information

Who Is Responsible For Your Bill? YOU and… (mark appropriate box(es))

Myself ONLY
Spouse
Worker’s Comp
Auto Insurance
Medicare
Medicaid
Other

Other (be specific)

Personal Health Insurance Carrier

Health ID Card #

Policy Holder’s Name

Group #

Policy Holder’s Date of Birth

Primary Care Physician

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Workers Compensation Injury / Auto / Personal Injury

Have you filed an injury report with your employer?

Date

Time

Carrier

Policy #

Carriers Phone #

Adjuster

Claim #:

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Confidential Patient Health Record

Personal Information

Emergency Contact

Employment Information

Current Health Condition

REVIEW OF SYSTEMS

PAST HEALTH HISTORY

Family History: Mark all that apply below. List any specific conditions past or present after has/had:

Social History

Insurance Information

Workers Compensation Injury / Auto / Personal Injury

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Confidential Patient Health Record

Personal Information

Emergency Contact

Employment Information

Current Health Condition

REVIEW OF SYSTEMS

PAST HEALTH HISTORY

Family History: Mark all that apply below. List any specific conditions past or present after has/had:

Social History

Insurance Information

Workers Compensation Injury / Auto / Personal Injury

Stop struggling, start living

Get Pain Relief Now – Pay only $49 for your first consultation Limited Time Offer

Get Pain Relief Now – Pay only $49 for your first consultation Limited Time Offer

Get Pain Relief Now –
Pay only $49 for your first consultation
Limited Time Offer

Get Pain Relief Now –
Pay only $49 for your first consultation
Limited Time Offer