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Chiropractic Clinic Dr Nassim Saba-Sayah, Via Madonnina, 10 20121 Milan (Italy)

PATIENT MEDICAL PROFILE

Please complete this form by marking the relevant boxes with an [X]

Milan, .......................

PERSONAL DATA

Name ................................................................................

Surname ..........................................................................

SSN (Codice Fiscale)…….…………………………………

Place of birth……...............................................................

Date of birth ...... / ...... / .......

First language (only if born or resident abroad): ..........................................................................................

Height: cm. ..........Weight: kg. ..........

[ ] right-handed [ ] left-handed [ ] ambidextrous

Occupation ....................................................................... ..........................................................................................

Address Street ...................................................... No. ..........

City..............................................Post code....................

Telephone

Home................................................................................

Work…..............................................................................

Mobile...............................................................................

E-mail ..............................................................................

Contact in case of emergency Name ................................................................................

Relationship with the patient...........................................

Phone No..........................................................................

FURTHER INFORMATION

How did you find our Center? ........................................................................................................................................ ....................................................................................................................................................................................... Job related fatigue / stress ….….................................................................................................................................... ....................................................................................................................................................................................... ....................................................................................................................................................................................... ....................................................................................................................................................................................... .......................................................................................................................................................................................

Physical activities Frequency

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2. Leisure activities Frequency

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CLINICAL DATA

Physician’s name, address and phone number .......................................................................................................................................................................................

Last examination date: ...... / ...... / ....... Name of the Specialist ..........................................................

Reason for the examination...........................................................................................................................................

Date of the last chiropractic examination: ...... / ...... / ....... Name of the Specialist ...................................................

Reason for the examination...........................................................................................................................................

What is your main health complaint at present?.....…………........................................................................................

Why have you turned to our Centre? ………................................................................................................................

On a scale from 1 (low) to 10 (high), what is the current intensity of your disorder? .................................................

When did the disorder first manifest itself? ...... / ...... / .......

With what symptoms?.................................................................................................................................................. Had it already manifested itself in the past? No [ ] Yes [ ] Specify: ….............................................................................................................................................................

What do you think caused the problem? ……………...............................................................................................

Did the symptoms manifest themselves: [ ] suddenly [ ] gradually

Frequency of the Disorder : [ ] continuous [ ] every hour [ ] several times a day

[ ] other ...................................................

The problem / episode lasts an average of [ ] ..... minutes [ ] ..... hours [ ] ..... days The problem interferes with your: [ ] work [ ] sleep [ ] daily activities [ ] leisure activities

What makes you feel better? ....................................................................................................................................

What makes you feel worse? ....................................................................................................................................

What other therapies [ ] have you received [ ] are you receiving, for this same problem? :

[ ] drugs [ ] surgery [ ] other: ..........................................................................................................................

3. Mr / Ms ................................................................................ Milan, .......................

The problem gets worse when you:

[ ] are sitting [ ] are standing

[ ] lift weights

[ ] make a rotation movement or other [ ] : ...........................................................................................

[ ] walk [ ] drive [ ] do sports / gym

[ ] fast [ ] eat [ ] eat a particular food or drink: .....................................

[ ] other .........................................................................................................................................................................

Have you been advised against certain [ ] foods or drinks [ ] movements [ ] activities

[ ] other: .......................................................................................................................................................................

Have you had any accidents?

[ ] No [ ] Yes , in which case please specify:

[ ] car accident ( on ...... / ...... / ....... )

[ ] work accident ( on ...... / ...... / ....... )

[ ] other ......................................................................................................................... ( on ...... / ...... / ....... )

FAMILY CASE HISTORY

Have any of your family members suffered from:

[ ] Alzheimer’s [ ] Parkinson’s [ ] TBC [ ] diabetes [ ] thyroid diseases

[ ] kidney diseases [ ] hypertension [ ] heart diseases [ ] stroke [ ] high cholesterol

[ ] Musculoskeletal disorders [ ] cancer [ ] anxiety or depression

[ ]

other: .........................................................................................................................................................................

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4. Using the symbols below, indicate the areas affected by the pain:

1 symbol, e.g. ( + ), for a light pain 2 symbols, e.g. ( ++ ), for a moderate pain 3 symbols, e.g. ( +++ ), for an intense pain 4 symbols, e.g. ( ++++ ), for an unbearable pain

Symbols: ( + ) numbness ( # ) hot – burning pain ( O ) pulsating pain

( / ) sharp – stabbing pain ( > ) intense pain ( K ) cramps

( Δ ) other ...................................................

( ) widespread – radiating pain (draw an arrow from where the pain starts to where the radiation travels)

5. PERSONAL MEDICAL HISTORY

Mr /Ms ................................................................................ Milan,.......................

COMPLAINT PRESUMED CAUSE SYMPTOMS START DATE

[ ] recent change in appetite

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[ ] swallowing difficulties

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[ ] recent significant weight change

how many kg. .................

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[ ] anemia

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[ ] gastrointestinal complaints list: ...............................................

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[ ] nausea, vomiting

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[ ] precancerous or cancerous conditions

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[ ] recurring allergies list: ...............................................

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[ ] evacuation disorders list: ...............................................

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[ ] urinary disorders list: ...............................................

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[ ] kidney disorders list: ...............................................

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[ ] diabetes

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[ ] breathing difficulties

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Exposure to:

[ ] chemicals

[ ] high levels of pollution

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COMPLAINT PRESUMED CAUSE SYMPTOMS START DATE

[ ] chest tightness or pain

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[ ] tachycardia, arrhythmia o palpitations

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[ ] hypertension

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[ ] edema and bleeding tendency

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[ ] headache

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[ ] ear disorders

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[ ] temporomandibular joint dysfunction

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[ ] pain in temples

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[ ] bruxism (teeth grinding)

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[ ] visual impairment list: ...............................................

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[ ] fainting

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[ ] epilepsy

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[ ] vertigo

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[ ] giddiness

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[ ] gland enlargement or dysfunction

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[ ] irritability and nervousness

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[ ] anxiety or depression

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[ ] frequent memory lapses

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DEPENDENCIES QUANTITY START DATE DENTAL PROBLEMS AND PROSTHESES START DATE

[ ] smoke [ ] alcohol [ ] medications

[ ] drugs

[ ] other ......................... ......................... .........................

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[ ] Any unresolved dental problems :

list ...................................................

[ ] Do you wear braces or a bite guard?

reason.................................................... [ ] Do you wear other prostheses?

reason.................................................... [ ] Do you use orthopedic prostheses or implants?

reason.................................................

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7. Mr / Ms ................................................................................ Milan, .......................

COMPLAINT PRESUMED CAUSE SYMPTOMS START DATE

[ ] insomnia

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[ ] other psychological disorders specify: .............................................

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[ ] osteoporosis

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[ ] rheumatoid arthritis

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[ ] other bone and joint disorders

list: ...............................................

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[ ] infectious diseases list: ...............................................

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[ ] malaise, fatigue, weakness

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[ ] other disorders list: ...............................................

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8.

Were you delivered by Caesarean section? [ ] No [ ] Yes

Have you had any surgical operations?

[ ] No [ ] Yes, (specify) ……….…..........................................................................................................................

Please list any admissions to private or public hospitals, the reasons for admission and the dates: .......................................................................................................................................................................................

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Please list any drugs you are currently taking: .......................................................................................................................................................................................

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How would you describe your sleep quality? [ ] good [ ] adequate [ ] poor

Estimate how many hours you sleep each night: .........

Preferred sleeping position: [ ] on your back [ ] on your tummy [ ] on your side Are you on a specific diet? [ ] No [ ] Yes, (specify) .........................................................................................

How many cups of coffee do you drink a day? ........

Are you currently pregnant? [ ] No [ ] Yes (How many months pregnant are you? .............. )

.................................................................................................. ................................... Signature of the Patient date

.................................................................................................. ................................... Signature of the Parent or Legal Guardian date

9. Mr / Ms ....................................................................

FURTHER PATIENT INFORMATION

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Mr / Ms....................................................................

FOR THE DOCTOR

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