HEALTH HISTORY QUESTIONNAIRE

All questions contained in this questionnaire are optional and will be kept strictly confidential

PATIENT INFORMATION
First Name: Last Name: Mr. Mrs. Age: / Cell phone: Work phone: Miss Ms. Height: Marital status (circle one) Single / Mar / Div / Sep / Wid Weight:

Sex: M Email: F

Birth date: /

Use for reminder calls Street address: City: State:

Use for reminder calls ZIP Code:

Occupation: Primary Physician:

Employer: Phone number:

Employer phone: Date last seen:

Emergency Contact:

Contact number:

Relationship to patient:

Chose clinic because/Referred to clinic by: Family Friend Close to home/work Internet search Doctor Other:

FOR OFFICE USE

CHIEF HEALTH CONCERN

What health concern(s) are you seeking treatment for?

Have you ever been diagnosed with the following? Asthma Seizures/epilepsy Hypertension High cholesterol Heart Disease Stroke Diabetes Thyroid problems Hepatitis HIV/AIDS Cancer Kidney Disease Osteoporosis Arthritis Tuberculosis

MEDICAL HISTORY

Please list any surgeries you have had:

Please list any prescription medication you are taking:

MUSCULO-SKELETAL PROBLEMS
Please circle areas where you experience pain

PALPATION EXAM RESULTS

Is the problem you are experiencing related to an injury? How long has this problem persisted? What is the nature of the pain? Please mark all that apply below: Comes and goes Dull Physical therapy Medication Light Constant Throbbing Chiropractic Cortisone injections Medium

Yes

No

With certain movements Feels hot Acupuncture Surgery Deep

Sharp Feels cold Massage

Have you sought any other treatment for this condition? If so, which apply?

For massage therapy, what kind of pressure do you prefer Dont know