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Health In Your Hands 302 Orchard Road #06-03 Singapore 238862 Phone: (+65) 6884 9820 Email: email@example.com www.scoliosis.com.sg PERSONAL HEALTH HISTORY Patient’s Name _________________________________________________ DOB _________________ Date __________________ The following form is to be completed prior to your consultation and emailed to the above contact details. Upon receiving the questionnaire, we will contact you via email to schedule your first consultation. Please complete the health history questionnaire. If you have any test results, etc. please feel free to attach copies along with any pertinent information not covered here. All information will be kept strictly confidential. Please check the degree of all conditions you currently have or have had. To be responsible for your case, we need your complete health history. O = Occasional F = Frequent C = Constant O F C O F C O F C Check any of the Muscle / Joint Eye, Ear, Nose and Throat Skin following conditions Arthritis Asthma Boils you currently have Bursitis Colds Bruise easily or have had: Foot trouble Crossed eyes Dryness Hernia Deafness Hives or allergy Alcoholism Low back pain Dental decay Itching Anemia Lumbago Earache Skin eruptions (rash) Appendicitis Neck pain, stiffness Ear discharge Varicose veins Arteriosclerosis Pain between shoulders Ear noise Cancer Enlarged glands Pain or numbness in Chicken pox General Enlarged thyroid Shoulders Cholera Allergy Eye pain Arms Cold sores Chills Failing vision Elbows Diabetes Convulsions Far sightedness Hand Diptheria Dizziness Gum trouble Hips Eczema Fainting Hay fever Legs Edema Fatigue Hoarseness Knees Emphysema Fever Nasal obstruction Feet Epilepsy Headache Near sightedness Painful tailbone Fever blisters Loss of sleep Nose bleeds Poor posture Goiter Loss of weight Sinus infection Sciatica Gout Nervousness, depression Sore throat Spinal curvature Heart disease Neuralgia Tonsillitis Swollen joints Herpes Numbness Respiratory Influenza Sweats Gastrointestinal Chest pain Lumbago Tremors Belching or gas Malaria Colitis Chronic cough Cardiovascular Difficult breathing Measles Colon trouble Hardening of arteries Constipation Spitting up blood Miscarriage High blood pressure Spitting up phlegm Multiple sclerosis Diarrhea Low blood pressure Difficult digestion Wheezing Mumps Pain over heart Pacemaker Bloated abdomen Women only Poor circulation Excessive hunger Congested breasts Pleurisy Rapid heartbeat Pneumonia Gallbladder trouble Cramps or backache Polio Slow heartbeat Hemorrhoids Excess menstrual flow Swelling of ankles Rheumatic fever Intestinal worms Hot flashes Scarlet fever Genitourinary Jaundice Irregular cycle Stroke Bed-wetting Liver trouble Lumps in breast Tuberculosis Blood in urine Nausea Menopause Typhoid fever Frequent urination Pain over stomach Painful menstruation Ulcers Lack of kidney control Poor appetite Vaginal discharge Venereal disease Kidney infection Vomiting Whooping cough Painful urination Vomiting of blood Are you pregnant? Yes No Prostate trouble If yes, how many months?____ Pus in urine How many children do you have?____ Describe your problem if scoliosis state the degree and type of curve: How long have you had this condition? Is it getting worse? Yes No Does it bother your (check appropriate box): Work Sleep Other (please specify) What seemed to be the initial cause? Are you under the care of a physician? Yes No If yes, for what reason? Health In Your Hands 302 Orchard Road #06-03 Singapore 238862 Phone: (+65) 6884 9820 Email: firstname.lastname@example.org www.scoliosis.com.sg Have you been hospitalized in the last 5 years? Yes No If yes, for major surgery? Yes No for serious injury? Yes No Have you had any mental or emotional disorders? Yes No If yes, when? Indicate the drugs do you now take? Birth control pills Tranquilizers Pain Killers Other (specify) Do you wear: heel lifts? sole lifts? inner soles? area supports? negative heels? platform shoes? How is most of your day spent? standing sitting walking other (specify) Have you ever: Yes No If yes, briefly explain. - had a broken bone? HABITS None Light Mod Heavy - been hospitalized? Alcohol - had strains or sprains? Coffee - used a cane, crutch or other support? Tobacco - been struck unconscious? Drugs - been hospitalized for other than surgery? Exercise Do you: Sleep - take minerals, herbs or vitamins? Appetite - think you need minerals, herbs or vitamins? Soft Drinks - have any drug allergy? Salty Foods Water When did you last have: Never 0-6 mos. 6 -18 mos. longer Sugar - spinal x-ray? - spinal examination? Artificial - physical examination? Sweeteners Please list any other health conditions you have been treated for, or surgery you have had in the last ten years. FAMILY HEALTH HISTORY: Information about your immediate family members, brothers, sisters, parents, and grandparents will give us a better understanding of your total health picture. RELATIONSHIP PRESENT AND PAST HEALTH PROBLEMS Please mark your areas of pain on the figures below. Draw your scoliosis if possible.
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