Back to Health P.C.1617A West Market

Johnson City, TN 37604

CURRENT HEALTH CONDITION (CON’T)

OCCUPATION: WORK(HRS/DAY):

JOBCLASSIFICATION:

LIFTINGFREQUENCY:

CONSTANT(66-100% DAY)

FREQUENT(33-65% DAY)

OCCASIONAL(0-32% DAY)

HOW DOES THIS CONDITIONEFFECT JOB PERFORMANCE:

MILD PAINFUL (CAN DO)

MODERATE PAINFUL (LIMITED)

SEVERE (UNABLE TO PERFORM)

OTHER (EXPLAIN):

WORK ACTIVITY POSTURES: (HRS/DAY)SITTING

STANDING

WALKING

CLIMBING

PUSHING

PULLING

REPETITIVE ACTIVITIES: (HRS/DAY)COMPUTER

PHONE

MACHINERY

HAND TOOLS

ASSEMBLY

GRASPING

KNEELING

REACHING

TWISTING

SITTING LIGHT MODERATE HEAVY LIFTING

EMPLOYMENT

NOEFFECT

ACTIVITY(place a check in column applicable)

MILD (CAN DO)

MODERATE(LIMITED)

SEVERE (UNABLE TO DO )

BendingCarrying GroceriesChange Posn-Sit-StandChild CareClimb StairsComputer UseDaily Pet CareDrivingExercise

GolfFishing

Household Chores

ACTIVITY(place a check in column applicable)

RunningSelf Care - DressingSelf Care - BathingSexual ActivitiesSleepStatic SittingStatic StandingSwimmingWalkingWeight LIftingYard Work

SINCE CONDITION BEGAN, HASANYTHING PERMANENTLY HELPED YOU?

YES

NO

YES

NOHAS ANYTHING THAT YOU HAVE DONE,THUS FAR, FIXED YOUR PROBLEM?

MODIFYING FACTORS -SYMPTOMS BETTER WITH:

ACTIVITY

BENDING

COLD

HEAT

MASSAGE

MOVEMENT

OTC MEDS

RX MEDS

REST

STRETCHING

SITTING

STANDING

TWISTING

WALKING

NOTHING HELPS

OTHERASSOC.SIGNS &SYMPTOMS:

ACHESCOLD LIMBDIZZINESSFATIGUE

FEVERHEARTBURNMUSCLE SPASMNAUSEA

NUMBNESSPALE BLUISH SKINPANICPINS & NEEDLES

RUNNY NOSESTIFFNESSSWEATINGSWELLING

TINGLINGVOMITINGWEAKNESS

QUALITY OFHEADACHES:

DULLSHARP

THROBBINGSTABBING

AURANO AURA

RADIATION:WEAKNESS:

LEFT

LEFT

RIGHT

RIGHT

BILATERAL

BILATERAL

ON A SCALE OF 0-10, (10 BEING THE WORST) RATE YOUR SYMPTOMS (RESTING): 0 1 2 3 4 5 6 7 8 9 10

ON A SCALE OF 0-10, (10 BEING THE WORST)

DURATION: SYMPTOM(S) STARTED:

SYMPTOM(S) LAST EPISODE:

TIMING WORSEIN THE:

SYMPTOM(S) WORSENED:

SYMPTOM(S) LAST OCCURRED:

INJURY OCCURRED:

ACCIDENT OCCURRED:

MORNING AFTERNOON NIGHT W/ACTIVITY CONSTANT INTERMITTENT

ASSOCIATEDSIGNS& SYMPTOMS:

BLURRED VISIONDEPRESSIONDIZZINESS

HEADACHESIRRITABILITY/MOOD SWINGLOCALIZED TINGLING

STIFFNESS

NAUSEA

RINGING IN EARSRADIATING

Reading (concentration)

Lifting

DAILY ACTIVITIES: TO WHAT LEVEL ARE YOU EXPERIENCING SYMPTOMS WHILE PERFORMING THESE ACTIVITIES

RATE YOUR SYMPTOMS (WITH ACTIVITY): 0 1 2 3 4 5 6 7 8 9 10

Hunting

BENDING

SLEEP DISTURBANCE

NOEFFECT

MILD (CAN DO)

MODERATE(LIMITED)

SEVERE (UNABLE TO DO )

SKIN: I DENYANY SKIN ISSUE(S)

CHANGES IN NAIL TEXTURECHANGES IN SKIN COLOR

HAIR GROWTHHAIR LOSS

HIVESITCHING

PARESTHESIA (NUMBNESS,PRICKLING, OR TINGLING)

RASHHISTORY OF SKIN DISORDERS

SKIN LESIONS/ULCERSVARICOSITIES

NERVOUS SYSTEM: I DENYANY NERVOUS SYSTEM ISSUE(S)

DIZZINESSFACIAL WEAKNESS

HEADACHESLIMB WEAKNESS

LOSS OF CONSCIOUSNESSLOSS OF MEMORY

NUMBNESSSEIZURES

SLEEP DISTURBANCESTRESS

STROKESTREMORS

UNSTEADINESSOF GAIT

HEMATOLOGY: I DENYANY HEMATOLOGIC ISSUE(S)

ANEMIABLEEDING

BLOOD CLOTTINGBLOOD TRANSFUSION(S)

BRUISES EASILYFATIGUE

LYMPH NODE SWELLING

ALLERGY: I DENY ANYALLERGY ISSUE(S)

ANAPHYLAXIS (HISTORYOF SNEEZING)

FOODINTOLERANCE

ITCHINGNASAL CONGESTION

SNEEZING

PSYCHOLOGIC: I DENY ANYPSYCHOLOGIC SYSTEM ISSUE(S)

ANHEDONIA (INABILITY TOEXPERIENCE JOY OR ENJOY LIFE)

ANXIETYAPPETITE CHANGES

BEHAVIORAL CHANGE(S)BIPOLAR DISORDER

CONFUSIONCONVULSIONS

DEPRESSIONINSOMNIA

MEMORY LOSSMOOD CHANGE(S)

CHILDHOODILLNESS:I DENY ANYCHILDHOOD ILLNESS(ES)

ADDALLERGIES/HAYFEVERASTHMAATOPIC DERMATITIS (ECZEMA)

BED WETTINGCEREBRAL PALSYCHICKEN POXDEPRESSION

DIABETESEAR INFECTIONSFETAL DRUGEXPOSURE

FOOD ALLERGIESHEADACHESHEPATITISHIV

MEASLESMUMPSRASHSCOLIOSIS

SEIZURE DISORDERSICKLE CELL ANEMIASPINA BIFIDAOTHER (PLEASE DESCRIBE)

ADULTILLNESS:I DENY ANYADULT ILLNESS(ES)

ALZHEIMERSANEMIAARTHRITISASTHMACANCERCHICKEN POXCROHN’S/COLITISCRPS (RSD)

OTHER

CVA (STROKE)CYSTIC KIDNEY DISEASEDEPRESSIONDIABETES (INSULIN)DIABETES (NON INSULIN)EAR INFECTIONS (FREQUENT)EMPHYSEMAEYE PROBLEMS

FIBROMYALGIAHEART DISEASEHEPATITISHIVHYPERTENSIONINFLUENZAL PNEUMONIALIVER DISEASELUNG DISEASE

LUPUS ERYTHEMA (DISCOID)LUPUS ERYTHEMA (SYSTEMIC)MULTIPLE SCLEROSISPARKINSON’S DISEASEPLEURISYPNEUMONIAPSYCHIATRIC PROBLEMSSCOLIOSIS

SEIZURE DISORDERSHINGLESSTD’S (UNSPECIFIED)SUICIDE ATTEMPT(S)THYROID PROBLEMSVERTIGOPAST HISTORY OF SIMILAR SYMPTOMSTO YOUR CURRENT CONDITION

CONSTITUTIONAL: I DENYANY CONSTITUTIONAL ISSUE(S)

CHILLSNIGHT SWEATS

WEIGHT GAINDAYTIME SOMNOLENCE (DROWSINESS)

FATIGUEFEVER

EYE/VISION: I DENYANY EYES/VISION ISSUE(S)

BLINDNESSDOUBLE VISION

EYE PAINPHOTOPHOBIA

TEARINGBLURRED VISION

FIELD CUTS CATARACTSGLAUCOMA

CHANGE IN VISIONITCHING (AROUND EYES)

WEAR GLASSES AND/ORCONTACT LENSES

EARS, NOSEAND THROAT:

I DENY ANYE/N/T ISSUE(S)

BLEEDINGDISCHARGEDIZZINESSSNORING

FAINTINGHEADACHESLOSS OF SMELLSORE THROATS (FREQUENT)

NASAL CONGESTIONSINUS INFECTIONSDENTAL IMPLANTS

EAR DRAINAGEEAR INFECTION(S)HEARING LOSSTINNITUS

POST NASAL DRIPDIFFICULTY SWALLOWINGEAR PAIN

HOARSENESSRHINORRHEA (RUNNY NOSE)SINUS INFECTIONSTMJ PROBLEMS

WEIGHT LOSS

RESPIRATION: I DENYANY RESPIRATORY ISSUE(S)

ASTHMA COUGHINGUP BLOOD

SPUTUMPRODUCTION

CARDIOVASCULAR:I DENY ANY

CARDIOVASCULARISSUE(S)

ANGINA (CHEST PAIN OR DISCOMFORT)CHEST PAINCLAUDICATION (LEG PAIN OR ACHINESS)

HEART MURMURHEART PROBLEMSORTHOPNEA (DIFFICULTYBREATHING WHILE LYING DOWN

SWELLING OF LEGSULCERSVARICOSE VEINS

PALPITATIONS (IRREGULAR OR FORCEFULBEATING OF THE HEART)PAROXYSMAL NOCTURNAL DYSPNEA (WAKINGAT NIGHT WITH SHORTNESS OF BREATH)

GASTROINTESTINALI DENY ANY

GASTROINTESTINALISSUE(S)

ABDOMINAL PAINBELCHINGBLACK, TARRY STOOLSCONSTIPATION

DIARRHEADIFFICULTY SWALLOWINGHEARTBURNHEMORRHOIDS

INDIGESTIONJAUNDICE (YELLOWING OF SKIN)NAUSEARECTAL BLEEDING

ABNORMAL STOOL CALIBER (QUALITY)

ABNORMAL STOOL COLORABNORMAL STOOL CONSISTENCYVOMITING

VOMITINGBLOOD

FEMALE I DENYANY FEMALE ISSUE(S)

BIRTH CONTROL THERAPYBREAST LUMP/PAINBURNING URINATION

CRAMPSFREQUENT URINATIONHORMONE THERAPY

IRREGULAR MENSTRUATIONURINE RETENTIONVAGINAL BLEEDING

VAGINAL DISCHARGE

MALE I DENY ANYMALE ISSUE(S)

BURNING URINATIONPROSTATE PROBLEMS

ERECTILEDYSFUNCTION

FREQUENT URINATIONURINATION RETENTION

HESITANCY/DRIBBLING

ENDOCRINE:I DENY ANY

ENDOCRINE ISSUE(S)

COLD INTOLERANCEDIABETES

EXCESSIVE APPETITEEXCESSIVE HUNGER

EXCESSIVE THIRSTFREQUENT URINATION

GOITERHAIR LOSS

HEAT INTOLERANCEUNUSUAL HAIR GROWTH

VOICE CHANGES

COUGH SHORTNESSOF BREATH

WHEEZING

Below is a list of diseases 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.

REVIEW OF SYMPTOMS - Please fill out all of the sections, even if “DENY”

(RINGINGIN EARS)

(VISUAL FIELD DEFECT)

PAST HEALTH HISTORY - Please f i l l out carefully as these problems can affect your overall course of care.

NAME

______ GENERAL FAMILY

______ FATHER

______ MOTHER

______ PATERNAL GRANDFATHER

______ PATERNAL GRANDMOTHER

______ MATERNAL GRANDFATHER

______ MATERNAL GRANDMOTHER

______ SON(S)

______ DAUGHTER(S)

______ BROTHER(S)

______ SISTER(S)

ALCOHOL: DIET:NEVERDAILY

BEERLIQUOR

WINEWEEKLYMONTHLY

SOCIALCONSUMPTION ONLY

DRUGS: DENY ANY ILLEGAL DRUG USEDENY USE OF IV DRUGS

HAVE NOT USED DRUGS SINCE_______HAVE USED DRUGS FOR _____________

TOBACCO: DENY TOBACCO USELIVE W/A SMOKER

# CHEWDAYWEEK

MONTH# PER:QUITSMOKING

HIGH FATHIGH FIBER

HIGH PROTEINHIGH SALT

LOW CALORIELOW CARB

LOW FIBERLOW SALT

LOWSUGAR

OZ.’S # GLASSESMark allthat apply.

I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself.Furthermore, I understand that the Chiropractic Clinic will prepare any necessary reports and forms to assist me in making collection from theinsurance company and that any amount authorized to be paid directly to the Chiropractic Clinic will be credited to my account upon receipt.However, I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible forpayment. I also understand that if I suspend or terminate my care or treatment, any fees for professional services rendered me will beimmediately due and payable. I hereby authorize the Doctor to treat my condition as he or she deems appropriate through the use ofChiropractic Health Care, and I give authority for these procedures to be performed. It is understood and agreed the x-rays are for examinationonly and the x-ray negative will remain the property of this office, being on file where they may be seen at any time while a patient of thisoffice. I also agree that I am responsible for all bills incurred at this office. I acknowledge that I have received the Chiropractic Clinic’s Noticeof Privacy Practices for protected health information.

PATIENT (PRINT NAME): PATIENT’S SIGNATURE: DATE:

DATE:GUARDIAN OR SPOUSE’S SIGNATURE OF AUTHORIZING CARE:(SIGNATURE INDICATES CONSENT TO TREAT)

XRev. 06/29

HAVE YOU SEEN OTHER DOCTORSFOR THIS CONDITION?

YES IF YES, WHO? (NAME)NO

PREVIOUS CHIROPRACTIC CARE? YES IF YES, WHO? (NAME)NO

WERE YOU SATISFIED WITH THERESULTS OF YOUR TREATMENT?

YES EXPLAIN:NO

ARE YOU CURRENTLY TAKING ANYPRESCRIPTION MEDICATIONS?

YES NO

DO YOU WEAR ANY OFTHE FOLLOWING?

HEAL LIFTSINNER SOLES

ARCH SUPPORTSORTHOTICS

ALLERGY MEDICATIONANTI-DEPRESSANTS

BLOOD PRESSURE MEDS.INSULIN

MUSCLE RELAXERSNERVE PILLS

PAIN KILLERSOTHER

LOCATION OFOFFICE:

TYPE OFTREATMENT:

IF YES, PLEASE MARKOR LIST (BE SPECIFIC).

(PLEASE SPECIFY)

PLEASE LIST ANY OTHER CONDITIONS YOU FEELWE SHOULD KNOW ABOUT - EVEN IF UNRELATED:

SURGERIES:I DENY ANYSURGERY (IES)

ANGIOPLASTYAPPENDECTOMYCAESAREAN SECTIONCARDIAC CATHETERIZATIONCARPAL TUNNEL REPAIR

CORONARY ARTERY BYPASSCOSMETICD & CDENTAL SURGERYGALL BLADDER

HEMORRHOIDECTOMYHERNIA REPAIRHYSTERECTOMYJOINT RECONSTRUCTIONJOINT REPLACEMENT

LAMINECTOMYMASTECTOMYPACEMAKER INSERTIONROTATOR CUFFSPINAL FUSION

TONSILLECTOMYOTHER (PLEASE BE SPECIFIC):

OB/GYN:I DENY ANYOB/GYN ISSUE(S)

I HAVE NEVER BEEN PREGNANTI HAVE BEEN PREGNANT IN THE PASTI AM CURRENTLY PREGNANT

MENSTRUAL HISTORY:

AGE OF ONSET ________

MY MENSES IS REGULARMY MENSES IS IRREGULARI AM CURRENTLY IN MENOPAUSE

INJURIES:I DENY ANYINJURY (IES)

BACK INJURYBROKEN BONESSEVERE FALL

FRACTUREDISABILITYHEAD INJURY

INDUSTRIAL ACCIDENTJOINT INJURYSEVERE LACERATION

MOTOR VEHICLE ACCIDENTMILD/MODERATE SOFT TISSUE INJURYSEVERE SOFT TISSUE INJURY

NON-DRUGALLERGIES:I DENY ANY NON-DRUG ALLERGIES

ANIMALS DAIRY EGGS FOOD COLORING MOLD POLLEN

IMMUNIZATIONS:I DENY ANYIMMUNIZATION(S)

DTaP (DIPTHERIA,TETANUS &PERTUSSIS)

FLUHEPATITIS AHEPATITIS B

HEPATITIS CINFLUENZAIPV (POLIO)

MMR (MEASLES, MUMPS & RUBELLA)PNEUMOCOCCALPPD (MANTOUX TEST-TB)

SMALL POXTBVARIVAX (CHICKEN POX)

WHUPPING COUGH(PERTUSSIS)

DATE OF LAST MENSES ________/________/________

PAST HEALTH HISTORY (CON’T)

PREVIOUS TREATMENT

FAMILY HISTORY - ENTER INITIALS BELOW: A = ALIVE D = DECEASED

RELATION PAST & PRESENT HEALTH PROBLEMS

SOCIAL HISTORY

PLEASE READ CAREFULLY AND SIGN BELOW