CONFIDENTIAL PATIENT CASE HISTORY
Please complete this questionnaire. This confidential history will be part of your permanent records.
Name: Date of Birth: Sex: M F
Address: City: State: 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 Mark only on the ones you now have or have had in the past.
General Now Past
Weakness
Fatigue
Fever Chills
Night Sweats
Fainting
Skin Now Past
Color Changes
Nail Changes Hair Changes
Moles
Rashes
Sores
Heart Now Past
Murmur
Palpitations
Rapid Heartbeat
Swollen Extremities
Cold Extremities
Chest Pain/Pressure
Varicose Veins
Blood Clots Throat Now Past
Pain
Soreness
Bad Tonsils Hoarseness
Trouble Swallowing
Recurrent Infections
Mouth Now Past
Bleeding Gums
Sores
Bad Breath
Loss of Taste
Dry Mouth Ulcers
Blisters
Neck Now Past
Neck Enlargement
Stiff neck
Soreness Lumps
Masses
Head Now Past
Injuries/Concussions
Bumps Last Eye Exam
Glasses
Contacts
Cataracts
Blood Now Past
Anemia
Low Blood Iron
Easy Bruising
Easy Bleeding Swollen Nodes
Painful Nodes
Breasts Now Past
Pain
Lumps
Discharge
Bleeding
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
Nose Now Past
Pain Bleeding
Decreased Smell
Discharge Obstruction
Post Nasal Drip
Runny Nose
Sinus Congestion
Lungs Now Past
Cough
Phlegm
Blood
Shortness of Breath
Wheezing Congestion
Ears Now Past
Earache Hard of Hearing
Deafness
Ringing in Ears
Discharge
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
Your current weight: Have you recently lost weight? Mental Work: Heavy Moderate Light Hours per day: Physical Work: Heavy Moderate Light Hours per day: Exercise: Heavy Moderate Light Hours per day: Smoking: Heavy Moderate Light Hours per day: Alcohol: Beer/Week Liquor/Week Wine/Week No. of Years Caffeine (Coffee, Tea, Cola): Cups/Day No. of Years Aspirin: No./Day No. of Years Other MARK THE AREAS OF YOUR SYMPTOMS ON THE FIGURES TO THE RIGHT Use the following symbols: Pain: p p p Numbness: o o o 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 Signature: Date: Parent/Guardian: Date:
Relative Age if Living Age at Death Cause of Death
State of Health
Illnesses
Father Mother
Brother(s) Sister(s)