Family Relationship Alive/Deceased Present Health/ Cause of Death Father Mother. # Alive Health #Deceased Cause of Death Brother Sisters Children/Ages
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- Shauna Fitzgerald
- 7 years ago
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1 Have you ever been treated with Acupuncture or Oriental Medicine? Chief Complaint Main problem/s you would like help with: How long ago did this problem begin? Does anything make it better or worse (e.g. heat, cold, massage, rest, fatigue, etc)? Have you been given a diagnosis for this problem? If so, what? What other kinds of treatment have you tried? Family Relationship Alive/Deceased Present Health/ Cause of Death Father Mother # Alive Health #Deceased Cause of Death Brother Sisters Children/Ages Check Illnesses which have occurred in any of your blood relatives: Diabetes Cancer Bleeding Tendency Kidney Disease Tuberculosis Heart Disease Stroke High Blood Pressure Nervous Illness Allergy Other Past Medical History Dates of significant illness or surgeries: Significant illnesses (please circle): Cancer Diabetes Hepatitis High Blood Pressure Seizures HIV/AIDS
2 Significant traumas (e.g. auto accident, falls, etc): Birth history: Allergies: Family medical history: Head, ears, eyes, nose, throat: Dizziness Concussions Migraine Glasses Eye strain Eye pain Poor vision Night blindness Color blindness Cataracts Blurry vision Earaches Ringing in the ears Poor hearing Grinding teeth Spots in front of eyes Facial pain Lip or tongue sores Teeth problems Jaw clicks Headaches Any other problems in this area? Cardiovascular: High blood pressure Low blood pressure Chest pain Irregular heartbeat Dizziness Fainting Cold hands or feet Swelling of the hands Swelling of the feet Blood clots Phlebitis Difficulty breathing
3 Any other problems with your heart or vascular system? Respiratory: Cough Coughing up blood Asthma Bronchitis Pneumonia Pain with deep breath Phlegm Any other problems with your lungs or respiration? Gastrointestinal: Nausea Vomiting Diarrhea Constipation Gas Belching Black stools Blood in stools Indigestion Bad breath Rectal pain Hemorrhoids Abdominal pain or cramps Chronic laxative use Any other problems with your stomach or intestines? Lifestyle Medicines, vitamins, herbs taken regularly within the last month? Occupation: Occupational stresses:
4 Do you follow a regular exercise program? Please describe: Have you ever been on a restricted diet? Please describe: Please describe your average daily diet: Morning: Afternoon: Night: Do you smoke? How many per day? How much coffee, tea or soda do you drink per week? How much alcohol do you drink per week? Please describe any drug use for non medical purposes: General (please check if you have had in the last three months): Poor appetite Poor sleeping Fatigue Fevers Chills Night sweats Sweat easily Tremors Cravings Localized weakness Poor balance Change in appetite Bleed or bruise easily Weight loss Weight gain Peculiar tastes or smells Strong thirst Sudden energy drop
5 Skin and Hair: Rashes Ulcerations Hives Itching Eczema Pimples Dandruff Loss of hair Recent moles Changes in hair or skin texture Any other skin problems? Uro Genital Painful urination Frequent urination Blood in urine Urgency to urinate Unable to hold urine Kidney stones Decrease in flow Impotency Sores on genitals Do you wake up to urinate? How often? Any particular color to urine? Any other problems with your urinary system or genitals? Pregnancy Number of pregnancies Number of births Premature births Miscarriages/abortions Age at first menses Number of days between menses Duration of menses Date of last menses Yeast infections Heavy or light period Painful periods Clots with flow Irregular periods Last Pap smear Vaginal discharge Vaginal sores Breast lumps PMS Do you use birth control? If so, what type and for how long?
6 Any other problems in this area? Musculoskeletal: Neck pain Muscle pains Knee pain Back pain Muscle weakness Foot/ankle pain Hand/wrist pains Shoulder pains Hip pain Any other joint or bone pain? Neuropsychological: Seizures Dizziness Loss of balance Areas of numbness Lack of coordination Poor memory Concussion Depression Anxiety Bad temper Easily susceptible to stress Any other neurological, psychological or mood problems? Comments: Please mention any other problems you would like help with or anything else you feel needs to be mentioned: Signature Date
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Name Home phone Work phone Address Email address Date of birth Gender (circle): M F Marital status No. of children Name of partner Referred by Have you ever seen a Chiropractor? No Yes (Who?): Insurance
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PATIENT REGISTRATION
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