Northtowns Chiropractic and Pain Management, Inc.
1967 Wehrle Drive, Suite 12
Williamsville, NY 14221
HEALTH QUESTIONNAIRE
TO SAVE TIME AND ALLOW US TO BETTER SERVE YOU, PLEASE COMPLETE ALL QUESTIONS
CONFIDENTIAL CASE HISTORY
Please Print Dr. Mr. Mrs. Ms. Miss Today's Date: ___________________
Name: (First) ______________________ (M) ___ (Last) ___________________ Home#: _________________Cell#:____________________
Address: _______________________________________________ City: _______________________ State: _____ Zip: _________________
SS No.:__________________ Date of Birth: ______________ Age: ______ Sex: M F E-mail: ____________________________________
Occupation: ________________________________ Employer: _________________________ Work#: _______________________________
Marital Status: ________________________ Spouse's Name: ____________________________ Spouse's occupation: ___________________
Primary Care Physician (Name, Address, and telephone #): ___________________________________________________________________
___________________________________________________________________________________________________________________
Who can we contact in case of an emergency? __________________________________Phone: _____________________________________
Whom may we thank for referring you to our office? ________________________________________________________________________
___________________________________________________________________________________________________________________
MAIN COMPLAINT: Why are you here today? Be specific with location: _______________________________________________________
1. When did it start? Date: ___________________
2. How did it start? Explain: ____________________________________________________________________________________________
3. Are today's complaints the result of a: Worker's Compensation Injury? Yes No Auto (No Fault) Accident? Yes No Home Injury? Yes No
4. Does it radiate to any other part of your body? Yes No If so, where? ________________________________________________________
5. Did it begin gradually or suddenly? ____________________________________
6. Rate the severity of your pain: (0 = NO Pain to 10 =Excruciating) (please Circle) 1 2 3 4 5 6 7 8 9 10
7. Describe your pain (DULL SHARP BURNING NUMBNESS SORENESS STIFFNESS) Other: _________________________________
8. Has your problem been getting BETTER, WORSE or STAYING about the SAME? _____________________________________________
9. Does your condition come and go or is it all the time? _____________________________________________________________________
10. What makes your symptoms better? __________________________________________________________________________________
11. What makes your symptoms worse? __________________________________________________________________________________
12. Have you tried home remedies? Yes No What? _________________________________________________________________________
13. What doctors have you seen and what tests have been done for your condition? ________________________________________________
14. Have you had anything like this before? Yes No Details: __________________________________________________________________
15. Have there been any changes in bowel or bladder functions? Yes No Details: __________________________________________________
16. Does your condition interfere with: WORK SLEEP DAILY ROUTINE RECREATION
Doctor's Initials: ________
Name: _________________________________________________________________ Today's Date: ______________________________
17. Activities or movements that are painful to perform: SITTING STANDING WALKING BENDING LAYING DOWN
18. Have you been unable to work as a result of your current problem? __________________________________________________________
19. Do you have any other problems that you would like the doctors to evaluate? __________________________________________________
___________________________________________________________________________________________________________________
PAST HISTORY:
1. Have you had any of the following childhood diseases: (CIRCLE) Measles Rubella Chickenpox Mumps Scarlet Fever Rheumatic Fever
2. Have you been diagnosed with any other conditions? Yes No Explain: ________________________________________________________
3. Are you under a doctor's care presently for any type of health problem? _______________________________________________________
4. Have you had any broken bones? Yes No If so, which ones? ________________________________________________________________
5. Have you ever had any significant auto accidents, work injuries or falls? Yes No When? _________________________________________
6. Are you taking any medication? Yes No If so, which ones? _________________________________________________________________
7. Have you ever undergone any type of surgery? Yes No If so, what and when? __________________________________________________
8. Do you eat regular meals? Yes No How many meals per day? ____ Snacks per day? _____
9. Do you smoke, drink alcohol, caffeine or use recreational drugs? ____________________________________________________________
10. Do you take vitamins or nutritional supplements? ________________________________________________________________________
11. Do you have any allergies? _________________________________________________________________________________________
12. Do any diseases run in your family? __________________________________________________________________________________
13. How often do you exercise? _________________________________________________________________________________________
14. Describe your work activity: Sitting Standing Light Labor Heavy Labor
15. How many hours per night do you usually sleep? _____ How do you sleep? On your: Back Side Stomach
16. Do you wear: Heel lifts Shoe lifts Arch supports Orthotics
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Have you been diagnosed or been told you have any of the Have you had any of these following symptoms for even a
following? (Please circle Yes or No) short or temporary duration within the last year?
YES NO High Blood Pressure YES NO Slurred speech or other speech problems
YES NO Hardening of the arteries YES NO Difficulty swallowing
YES NO Diabetes YES NO Dizziness
YES NO Heart or blood vessel disease YES NO Temporary lack of understanding
YES NO Bone spurs on the neck YES NO Loss of consciousness, even momentary blackouts
YES NO Whiplash injury YES NO Numbness of loss of sensation in the face, arms, hands, fingers,
YES NO Any relatives ever suffer a stroke or legs
YES NO Blurred vision YES NO Any other abnormal or loss in any other part of your body
YES NO Double vision YES NO Weakness, clumsiness, or strength loss in the face, arms, hands,
YES NO Do you currently smoke? fingers, or legs
YES NO Have you smoked in the past? YES NO Hearing loss in one or both ears
YES NO Sudden collapse without loss of consciousness
YES NO Diminished or partial loss of vision in one or both eyes
Doctor's Initials: _______
Name: _____________________________________________________________________Today’s Date: ________________________
GENERAL SYMPTOMS:
GENERAL: GASTROINTESTINAL: EYE EAR NOSE THROAT: MEN ONLY:
Bruise easily Appetite poor Bleeding gums Breast lump
Chills Bloating Blurred vision Erection difficulties
Dental problems Bowel changes Crossed eyes Lump in testicles
Depression Constipation Difficulty swallowing Penis discharge
Difficulty sleeping Diarrhea Double vision Sore on penis
Dizziness Excessive hunger Earache Other: _______________
Fainting Excessive Thirst Ear discharge Difficulty with urination
Fever Gas Hay fever Excessive urination
Forgetfulness Hemorrhoids Hoarseness Date of last prostate exam:
____________________
Headache Indigestion Loss of hearing
WOMEN ONLY:
Loss of sleep Nausea Nosebleeds
Abnormal pap smear
Nervousness Rectal bleeding Persistent cough
Bleeding between periods
Numbness Stomach pain Ringing in ears
Breast lump
Sweats Vomiting Sinus problems
Extreme menstrual pain
Tiredness Vomiting blood Vision -flashes
Hot flashes
Weight gain CARDIOVASCULAR: Vision -halos
Nipple discharge
Chest pain SKIN:
Painful intercourse
High blood pressure Bruise easily
Vaginal discharge
Irregular heart beat Hives
Other: ________________
Low blood pressure Itching
Date of last menstrual period: ____
Poor circulation Change in moles
Date of last Pap smear: __________
Rapid heart beat Rash Have you had a mammogram: ____
Do you take birth control pills? ___
Swelling of ankles Scars
If yes, for how long? _____
Varicose veins Sore that won't heal
Are you pregnant: ____?
Number of children: _____
ATTENTION: Payment is to be made at the time of the visit unless prior arrangements have been made with this office.
Also, 24-hour notice is necessary to cancel an appointment, and you may be responsible for payment of a missed appointment.
I hereby consent to any procedures or treatments necessary for treatment of any condition as deemed reasonable by the attending
doctor.
PATIENT SIGNATURE: _____________________________________________ DATE: ___________ Doctor's Initials: _______