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:

CHIEF HEALTH CONCERN

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

FOR OFFICE USE

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:

Check if you have, or have had, any symptoms in the following areas to a significant degree Abdominal pain Acid reflux, indigestion Distension/bloating Low appetite Nausea Tendency to loose stools Constipation Hemorrhoids Organ prolapse Gallbladder problems Bladder control issues Difficulty with urination Water retention/edema Rashes , skin eruptions Psoriasis, eczema Frequent Colds Sinus problems Chronic cough Difficulty breathing Irregular heart beat Chest pain Cold hands/feet Eye or vision problems Ear or hearing problems Ringing ears Gum or tooth problems Fainting, dizziness, vertigo Tremors, convulsions Poor memory/concentration Headache, migraines Difficulty sleeping Night sweats Predominant emotion: Worry Anger Irritability Depression Fear Grief/sadness Recent changes in: Weight Energy level Ability to sleep Pain: Neck Upper back Lower back Hips Knees Ankles Elbows Wrists

OTHER PROBLEMS

HEALTH HABITS AND LIFESTYLE

Exercise Caffeine Sedentary (No exercise) None # of cups/cans per day? Alcohol Do you drink alcohol? How many drinks per week? Tobacco Do you use tobacco? If no, have you smoked in the past Cigarettes /day Stress Rank stress levels Hi # of years Med Yes Yes Or year quit Low No No Yes No Irregular exercise Coffee Regular mild exercise Tea Regular vigorous exercise Soda

WOMEN ONLY
Age at onset of menstruation: Period PMS Other Heavy Breast tenderness Mid-cycle spotting Date of last menstruation: Painful Bloating Night sweats Clots in blood Irritability Hot flashes Date of last pap? Period every _____ days Mucus in blood Weepiness Excess vaginal discharge

List birth control, if any:

MUSCULO-SKELETAL PROBLEMS
Please circle areas where you experience pain

Is the pain 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 Constant Throbbing Chiropractic Cortisone injections

Yes

No

With certain movements Feels hot Acupuncture Surgery

Sharp Feels cold Massage

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

PALPATION EXAM FOR OFFICE USE