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Patient Intake Form - Optimal Health Chiropractic

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Patient Intake Form - Optimal Health Chiropractic Powered By Docstoc
					                                      Confidential Patient Data
             IF YOU NEED ASSISTANCE COMPLETING THIS FORM, PLEASE ASK THE RECEPTIONIST

PATIENT INFORMATION                                          Today’s Date_________________________
Name:_______________________________________________ Date of Birth:__________________________
Address:___________________________City:________________State:_____Zip:__________
Phone(H):_____________________(W):__________________(C)________________________
Email:_______________________________
Age:__________       Male       Female
Marital Status:      Married       Single     Divorced    Widowed       Other
Name of Spouse or Nearest Relative:_______________________Phone:__________________
Your Occupation:___________________________Employer:____________________________

Referred to this office by:     Friend/Family member: ________________________________
    Yellow pages        Internet      Sign      Other_________________________________
Payment for services will be by:      Health Insurance     Cash/Check/Credit Card
    Auto Insurance         Workers’ Compensation Insurance
Name of Insurance Co:__________________________________________________________
Are you covered by more than one insurance company?        Yes    No    Name:__________________________


MEDICAL/FAMILY HISTORY                S=SELF M=MOTHER F=FATHER
S     M     F                         S    M   F                           S   M      F
                AIDS                               Epilepsy                               Nervousness
                Anemia                             German measles                         Numbness
                Arthritis                          Headaches                              Polio
                Asthma                             Heart trouble                          Poor circulation
                Back Pain                          Reproductive disorder                  Hepatitis
                Bladder trouble                    High blood pressure                    rheumatic fever
                Bone fracture                      HIV/ARC                                rheumatism
                Cancer                             Kidney disorder                        Scarlet Fever
                Chest pain                         Bowel control loss                     Serious Injury
                Concussion                         Menstrual cramps                       Sinus trouyble
                Convulsions                        multiple sclerosis                     Tuberculosis
                Diabetes                           muscular dystrophy                     Venereal disease
                Dislocated joints                  Neck pain

Have you been treated by a physician for any health condition in the last year? Yes No
Describe condition:________________________________________________________________
Date of last physical exam:____________________________________

SURGICAL HISTORY:
1.____________________________________________________ DATE:___________________________________
2.____________________________________________________ DATE:___________________________________
3.____________________________________________________ DATE:___________________________________
Have you ever had a metal implant?  Yes     No Have you ever been gunshot?     Yes     No

ACCIDENT HISTORY:        Job        Auto   Other 1.____________________________Date:_________________
                        Job         Auto   Other 2.____________________________Date:_________________
                        Job         Auto   Other 3.____________________________Date:_________________
PLEASE DESCRIBE PRESENT MAJOR COMPLAINTS:
         (Please rate symptoms 1 -10, with 1 being least serious)
                                      Symptom                                Rating
1._____________________________________________________________                  ________

2._____________________________________________________________                  ________

3._____________________________________________________________                 ________

4._____________________________________________________________                 ________

5._____________________________________________________________                 ________

6._____________________________________________________________                 ________

Symptoms are worse in:   Morning   Afternoon    Night

When and how occurred?___________________________________________________________________________

Symptoms developed from: Job related injury Auto accident Other accident Illness Unknown cause
Onset: Gradual or Sudden                  Date occurred:____________________
Symptoms have persisted for: # ____Hour(s) ____Day(s) ____Week(s) ____Month(s) ____Year(s)
Symptoms/Complaints: Come & Go              Are constant
Have you ever had this before?: No          Yes     When?_______________________________________________
If you were to guess, what do you think is causing your complaints?
______________________________________________________ __________________________________________
Name and location of medical professionals previously seen for present condition(s):
________________________________________________________________________________________________
_________________________________________________________________________________________________
Are you allergic to any medications? No Yes What kind?__________________________________________
Are you taking any medications?No Yes What kind?_____________________________________________
Are you pregnant?NoYes Date of LMP ___/____/____ If pregnant, what trimester?____________________
Are you wearing contacts? No Yes               Dentures? No Yes

PLEASE CHECK THE FOLLOWING ACTIVITIES THAT AGGRAVATE YOUR CONDITION:
Bending Reaching Straining at stool Coughing Sitting Turning headLifting           Sneezing
Standing Walking Lying down

PLEASE CHECK THE FOLLOWING ACTIVITIES THAT RELIEVE YOUR CONDITION:
Bending Sitting Lifting Standing Lying down Turning head Reaching Walking

PLEASE CHECK ANY ADDITIONAL SYMPTOMS YOU MAY BE EXPERIENCING:
blurred vision bruising buzzing in ears cold feet cold hands cold sweats concentration
loss/confusionconstipation depression/weeping spells diarrhea dizziness face flushed fainting fatigue
fever head seems too heavy headaches insomnia light bothers eyes loss of balance loss of smell loss
of taste low resistance to colds muscle jerking muscle tensionnumbness in fingers numbness in toes
pins and needles in arms pins and needles in legs ringing in ears shortness of breath stiff neck
stomach upset touch/pressure sensitivity

FOR MASSAGE THERAPY:
Have you had massage therapy before? Yes No        Date of last session: ______________________
What kind of pressure do you prefer?  light  medium firm

Patient's Signature:___________________________________    Date:____________________ __

				
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posted:8/14/2011
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