CONFIDENTIAL PATIENT CASE HISTORY

Please complete this questionnaire. This confidential history will be part of your permanent records.

Name: Date of Birth: Sex: M F

Address: City: State: 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 Mark only on the ones you now have or have had in the past.

General Now Past

Weakness

Fatigue

Fever Chills

Night Sweats

Fainting

Skin Now Past

Color Changes

Nail Changes Hair Changes

Moles

Rashes

Sores

Heart Now Past

Murmur

Palpitations

Rapid Heartbeat

Swollen Extremities

Cold Extremities

Chest Pain/Pressure

Varicose Veins

Blood Clots Throat Now Past

Pain

Soreness

Bad Tonsils Hoarseness

Trouble Swallowing

Recurrent Infections

Mouth Now Past

Bleeding Gums

Sores

Bad Breath

Loss of Taste

Dry Mouth Ulcers

Blisters

Neck Now Past

Neck Enlargement

Stiff neck

Soreness Lumps

Masses

Head Now Past

Injuries/Concussions

Bumps Last Eye Exam

Glasses

Contacts

Cataracts

Blood Now Past

Anemia

Low Blood Iron

Easy Bruising

Easy Bleeding Swollen Nodes

Painful Nodes

Breasts Now Past

Pain

Lumps

Discharge

Bleeding

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

Nose Now Past

Pain Bleeding

Decreased Smell

Discharge Obstruction

Post Nasal Drip

Runny Nose

Sinus Congestion

Lungs Now Past

Cough

Phlegm

Blood

Shortness of Breath

Wheezing Congestion

Ears Now Past

Earache Hard of Hearing

Deafness

Ringing in Ears

Discharge

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

Your current weight: Have you recently lost weight? Mental Work: Heavy Moderate Light Hours per day: Physical Work: Heavy Moderate Light Hours per day: Exercise: Heavy Moderate Light Hours per day: Smoking: Heavy Moderate Light Hours per day: Alcohol: Beer/Week Liquor/Week Wine/Week No. of Years Caffeine (Coffee, Tea, Cola): Cups/Day No. of Years Aspirin: No./Day No. of Years Other MARK THE AREAS OF YOUR SYMPTOMS ON THE FIGURES TO THE RIGHT Use the following symbols: Pain: p p p Numbness: o o o 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 Signature: Date: Parent/Guardian: Date:

Relative Age if Living Age at Death Cause of Death

State of Health

Illnesses

Father Mother

Brother(s) Sister(s)