adult patient questionnaire - canning chiro · what relieves the problem? what aggravates the...
TRANSCRIPT
CONFIDENTIAL PATIENT INFORMATION First Name: Last Name: Today’s Date:
Address: City: State: Zip:
Cell Phone: Other Phone: Email:
Birthdate: Sex: SS#:
Marital Status: # of Children: Occupation:
Emergency Contact: Emergency Phone: Emergency Relationship:
How did you hear about us?
Who is your Primary Care Physician?
Are you also receiving care from other health professionals? If yes, Name of Professional and specialty:
What is your Primary Complaint that prompted you to seek care?
When did this begin?
How did this begin?
What relieves the problem?
What aggravates the problem?
Has this problem? Gotten Worse Stayed Constant Come and gone
Other treatment that you have sought for this problem?
Medication Surgery Physical Therapy Acupuncture Chiropractic Massage Ice Heat
What is your Secondary Complaint?
When did this begin?
How did this begin?
What relieves the problem?
What aggravates the problem?
Has this problem? Gotten Worse Stayed Constant Come and gone
Other treatment that you have sought for this problem?
Medication Surgery Physical Therapy Acupuncture Chiropractic Massage Ice Heat
Please indicate below where you are
experiencing pain or discomfort
Adult Patient Questionnaire
Review of health history
Check any condition you HAVE (at present) and any you have HAD (in the past)
Have Had GENERAL Dizziness Trouble swallowing
Fainting / Unexpected Fall Slurred or Slow Speech
Visual Disturbance Nausea
Numbness / Tingling Poor Co-ordination
Have Had CARDIOVASCULAR Blood Clot / Disorder Heart Attack Stroke Chest pain Low / High blood pressure Excessive Bruising
Have Had GENITOURINARY PMS symptoms Kidney infection / stones Prostate issues Difficulty / uncontrollable urination Infertility Bedwetting
Have Had NEUROLOGICAL Anxiety Depression Headache Ringing in ears Weakness
Have Had DIGESTIVE Heartburn / Ulcers Vomiting Food sensitivities Constipation Diarrhea
Have Had RESPIRATORY Hay fever Pneumonia Shortness of breath Asthma Apnea Emphysema
Arthritis Cancer Diabetes Genetic Disorders Osteoporosis Fever / Sweats Rapid weight loss / gain Pain with cough / sneeze / toilet
Yes No WOMEN Are you taking birth control? Are you pregnant? Are you nursing?
Is there anything else we should know about your health?
Yes No Note any significant family medical history:
TOXIN: Chemical and Environmental Exposure
List any drugs / medication / vitamins / herbs / that you are taking: Please rate your CONSUMPTION for each
Cigarettes ---------O---------O---------O--------O--------O Water---------------O---------O---------O--------O--------O Processed Foods-O---------O---------O--------O--------O Alcohol-------------O---------O---------O--------O--------O
TRAUMAS: Physical Injury History
Have you ever had any significant falls, surgeries, car accidents or
other injuries?
Notable childhood injuries?
None Moderate High
THOUGHTS: Emotional Stresses and Challenges
Please rate your STRESS for each:
Home ---------O---------O---------O--------O--------O Work ---------O---------O---------O--------O--------O Life ---------O---------O---------O--------O--------O
Notes:
None Moderate High
ACKNOWLEDGEMENT & CONSENT
Name: _________________________________________________ Date:____________________
Canning Chiropractic | www.canningchiro.com 78 Scenic Hwy, Lawrenceville, GA, 30046 | (770) 513 - 1591
TOXIN: Chemical and Environmental Exposure
Have Had