CONFIDENTIAL PATIENT CASE HISTORY
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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.
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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 □ □
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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 ________________