CONFIDENTIAL PATIENT CASE HISTORY

Continue to Page 2

Please complete this questionnaire. This confidential history will be part of your permanent records.

Name ______________________________________________ Date of Birth _______________________ Sex □ M □ F

Address _______________________________________________________ City ____________________ Zip________

E-Mail ___________________________________________ Cell Phone ______________________________________

Soc. Sec. #_____________________________Work Phone _____________________ Home Phone _________________

Marital Status: □ M □ S □ D □ W Children, Ages ______________________ Spouse’s Name ___________________

Occupation ____________________________ Employer ____________________________________________________

Who referred you to us? _____________________________ How else did you hear about us? _____________________

What is your major complaint? ________________________________________________________________________

__________________________________________________________________________________________________

How long have you had this condition? __________________________________________________________________

Have you had this or similar conditions in the past? ________________________________________________________

Do any positions make it feel worse? ____________________________________________________________________

Do any positions make it feel better? ____________________________________________________________________

Is this condition: □ Improving □ Unchanged □ Getting Worse

Is this condition interfering with your: □ Work □ Sleep □ Daily Routine Other _____________________________

Other doctors or therapists who have treated THIS condition ________________________________________________

What do you think caused this condition? ________________________________________________________________

List surgical operations and years: ______________________________________________________________________

__________________________________________________________________________________________________

Do you have a family physician? Name __________________________________________________________________

Medications, dosage and frequency: ____________________________________________________________________

__________________________________________________________________________________________________

Have you been in an auto accident or had any other personal injury? □ Y □ N Describe _________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

REVIEW OF SYSTEMS Check only the ones you now have or have had in the past.

Page 2

GENERAL NOW PAST

Weakness □ □

Fatigue □ □

Fever □ □

Chills □ □

Night Sweats □ □

Fainting □ □

SKIN NOW PAST

Color Changes □ □

Nail Changes □ □

Hair Changes □ □

Moles □ □

Rashes □ □

Sores □ □

HEAD NOW PAST

Injuries/Concussions □ □

Bumps □ □

Last Eye Exam ____________

Glasses □ □

Contacts □ □

Cataracts □ □

EARS NOW PAST

Earache □ □

Hard of Hearing □ □

Deafness □ □

Ringing in Ears □ □

Discharge □ □

NOSE NOW PAST

Pain □ □

Bleeding □ □

Decreased Smell □ □

Discharge □ □

Obstruction □ □

Post Nasal Drip □ □

Runny Nose □ □

Sinus Congestion □ □

MOUTH NOW PAST

Bleeding Gums □ □

Sores □ □

Bad Breath □ □

Loss of Taste □ □

Dry Mouth □ □

Ulcers □ □

Blisters □ □

THROAT NOW PAST

Pain □ □

Soreness □ □

Bad Tonsils □ □

Hoarseness □ □

Trouble Swallowing □ □

Recurrent Infections □ □

NECK NOW PAST

Neck Enlargement □ □

Stiff Neck □ □

Soreness □ □

Lumps □ □

Masses □ □

BREASTS NOW PAST

Pain □ □

Lumps □ □

Discharge □ □

Bleeding □ □

LUNGS NOW PAST

Cough □ □

Phlegm □ □

Blood □ □

Shortness of Breath □ □

Wheezing □ □

Congestion □ □

HEART NOW PAST

Murmur □ □

Palpitations □ □

Rapid Heartbeat □ □

Swollen Extremities □ □

Cold Extremities □ □

Chest Pain/Pressure □ □

Varicose Veins □ □

Blood Clots □ □

BLOOD NOW PAST

Anemia □ □

Low Blood Iron □ □

Easy Bruising □ □

Easy Bleeding □ □

Swollen Nodes □ □

Painful Nodes □ □

GASTROINTESTINAL NOW PAST

Abdominal Pain □ □

Nausea □ □

Bloated □ □

Belching □ □

Heartburn □ □

Indigestion □ □

Irregular Bowel Habits □ □

Constipation □ □ Diarrhea □ □ Gas □ □ Hemorrhoids □ □ Poor Appetite □ □ Food Intolerance □ □ Bloody Stools □ □ Black Stools □ □

Continue to Page 4

GENITOURINARY NOW PAST

Urgency □ □

Incontinence □ □

Straining □ □

Frequent Voiding □ □

Burning □ □

Bed Wetting □ □

Discharge □ □

Impotence □ □

Cloudy Urine □ □

Urine Color _____________

Menstrual Cramps □ □

Itching □ □

Irregular Periods □ □

Hot Flashes □ □

PSYCHIATRIC NOW PAST

Insecurity □ □

Depression □ □

Troubled Sleep □ □

Timid □ □

Loss of Memory □ □

Alcoholism □ □

Drug Addiction □ □

Drug Dependent □ □

Suicidal Thoughts □ □

Extreme Worry □ □

PAST MEDICAL HISTORY. Check only the ones you have had in the past.

Hay Fever □ Epilepsy □

Mumps □ Paralysis □

Rheumatic Fever □ Polio □

Allergies □ Mental Illness □

Angina □ Gout □

Cancer □ Hemorrhoids □

Tumors □ Prostate Problems □

Blood Disease □ Diabetes □

Leukemia □ Bladder Trouble □

Heart Trouble □ Kidney Stones □

Varicose Veins □ Kidney Infections □

Phlebitis □ Gallstones □

Hypertension □ Hepatitis □

Stroke □ Parasites □

Ulcers □ Liver Trouble □

MUSCULOSKELETAL NOW PAST

Muscle Pain □ □

Muscle Weakness □ □

Muscle Cramps □ □

Muscle Twitching □ □

Joint Stiffness □ □

Joint Pain □ □

Neck Pain □ □

Mid Back Pain □ □

Low Back Pain □ □

Headaches □ □

Foot Pain □ □ Flat Feet □ □ Wearing Shoe Orthotics? □ □

What Kind of Pillow Do You Use?

________ ________

NEUROLOGIC NOW PAST

Seizures □ □

Vertigo □ □

Dizziness □ □

Hand Trembling □ □

Loss of Sensation □ □

Incoordination □ □

Paralysis □ □

Speech Difficulty □ □

Tingling in Arms/Hands □ □

Tingling in Legs/Feet □ □ Numbness in Arms/Hands □ □

Numbness in Arms/Hands □ □

Loss of Memory □ □

NOW PAST Do You Experience Jaw/TMJ Pain? □ □ Do You Experience Headaches? □ □

Please Describe ___________ ___________ ___________

FAMILY & SOCIAL HISTORY

Relative Age if Living Age at Death Cause of Death State of Health Illnesses Father _______ _______ _______________ ______________ ____________________

Mother _______ _______ _______________ ______________ ____________________

Brother(s) _______ _______ _______________ ______________ ____________________

Sister(s) _______ _______ ______________ ______________ ____________________

_____

Your Current Weight ___________ Have you recently lost or gained weight? ___________________________

Mental Work

Physical Work

Exercise

Smoking

Alcohol

Caffeine

Aspirin

MARK THE AREAS OF YOUR SYMPTOMS ON THE FIGURES TO THE RIGHT.

Use the following symbols:

Pain: ∆ ∆ ∆ Numbness: ○ ○ ○ Pins/Needles: X X X

MARK AN “ X ” ON THE LINES BELOW: How bad are your symptoms now?

0 5 10 No Symptoms Most Severe

How bad have they been in the past?

0 5 10 No Symptoms Most Severe

□ Heavy □ Moderate □ Light Hours per day ________

□ Heavy □ Moderate □ Light Hours per day ________

□ Heavy □ Moderate □ Light Hours per week _______ Type ____________________

-_________________

□ Current □ Previous Packs/Day ______ No. of years _______

Beer/Week ______ Liquor/Week _______ Wine/Week _______ No. of Years ________

Cups/Day ______ No. of Years ______ (Coffee, Tea, Cola)

No./Day ______ No. of Years ______ Others ________________________________

Signature __________________________________________________________________ Date ________________

Parent/Guardian ____________________________________________________________ Date ________________