Personal Health History

Patient’s Name _________________________________________________ DOB _________________ Date __________________

All information will be kept strictly confidential. Your responses will help determine if chiropractic treatment will benefit you. Unless we sincerely feel that your condition will respond satisfactorily, we will not recommend treatment. Please check the degree of all conditions you currently have or have had. To be responsible for your case, we need your complete health history.

O = Occasional F = Frequent C = Constant

O	F	C

Muscle / Joint

Arthritis

Bursitis

Foot trouble

Hernia

Low back pain

Lumbago

Neck pain, stiffness

Pain between shoulders

General

Allergy

Chills

Convulsions

Dizziness

Fainting

Fatigue

Fever

Headache

Loss of sleep

Loss of weight

Nervousness, depression

Neuralgia

Numbness

Sweats

Tremors

Cardiovascular

Hardening of arteries

High blood pressure

Low blood pressure

Pain over heart

Poor circulation

Rapid heartbeat

Slow heartbeat

Swelling of ankles

Genitourinary

Bed-wetting

Blood in urine

Frequent urination

Lack of kidney control

Kidney infection

Painful urination

Prostate trouble

Pus in urine

O	F	C

Eye, Ear, Nose and Throat

Asthma

Colds

Crossed eyes

Deafness

Dental decay

Earache

Ear discharge

Ear noise

Enlarged glands

Enlarged thyroid

Eye pain

Failing vision

Far sightedness

Gum trouble

Hay fever

Hoarseness

Nasal obstruction

Near sightedness

Nose bleeds

Sinus infection

Sore throat

Tonsillitis

Gastrointestinal

Belching or gas

Colitis

Colon trouble

Constipation

Diarrhea

Difficult digestion

Bloated abdomen

Excessive hunger

Gallbladder trouble

Hemorrhoids

Intestinal worms

Jaundice

Liver trouble

Nausea

Pain over stomach

Poor appetite

Vomiting

Vomiting of blood

O	F	C

Skin

Boils

Bruise easily

Dryness

Hives or allergy

Itching

Skin eruptions (rash)

Varicose veins

Pain or numbness in

Shoulders

Arms

Elbows

Hand

Hips

Legs

Knees

Feet

Painful tailbone

Poor posture

Sciatica

Spinal curvature

Swollen joints

Respiratory

Chest pain

Chronic cough

Difficult breathing

Spitting up blood

Spitting up phlegm

Wheezing

Women only

Congested breasts

Cramps or backache

Excess menstrual flow

Hot flashes

Irregular cycle

Lumps in breast

Menopause

Painful menstruation

Vaginal discharge

Are you pregnant? Yes No

____ If yes, how many months?____

How many children do you have?

Check any of the following conditions

you currently have

or have had:

Alcoholism

Anemia

Appendicitis

Arteriosclerosis

Cancer

Chicken pox

Cholera

Cold sores

Diabetes

Diptheria

Eczema

Edema

Emphysema

Epilepsy

Fever blisters

Goiter

Gout

Heart disease

Herpes

Influenza

Lumbago

Malaria

Measles

Miscarriage

Multiple sclerosis

Mumps

Pacemaker

Pleurisy

Pneumonia

Polio

Rheumatic fever

Scarlet fever

Stroke

Tuberculosis

Typhoid fever

Ulcers

Venereal disease

Whooping cough

Describe chiropractic problem:

How long have you had this condition? Is it getting worse? Yes No
Does it bother your (check appropriate box): Work Sleep Other (please specify)
What seemed to be the initial cause?
Have you seen a chiropractor before? Yes No If yes, how long ago? ________ For what reason?
Are you under the care of a physician? Yes No If yes, for what reason?

Patient’s Name _________________________________________________ DOB _________________ Date __________________

Have you been hospitalized in the last 5 years? Yes No If yes, for major surgery? Yes No for serious injury? Yes No
Have you had any mental or emotional disorders? Yes No If yes, when?
Indicate the drugs do you now take? Birth control pills Tranquilizers Pain Killers Other (specify)
Do you wear: heel lifts? sole lifts? inner soles? area supports? negative heels? platform shoes?
What is the age of your mattress? Is it comfortable? uncomfortable? Do you use a bedboard? Yes No
How is most of your day spent? standing sitting walking other (specify)

HABITS	None Light Mod Heavy	Alcohol	Coffee	Tobacco	Drugs	Exercise	Sleep	Appetite	Soft Drinks	Salty Foods	Water	Sugar	Artificial	Sweeteners	Have you ever:	Yes No	If yes, briefly explain.

- had a broken bone?

- been hospitalized?

- had strains or sprains?

- used a cane, crutch or other support?

- been struck unconscious?

- been hospitalized for other than surgery?

Do you:

- take minerals, herbs or vitamins?

- think you need minerals, herbs or vitamins?

- have any drug allergy?

When did you last have:	Never 0-6 mos. 6 -18 mos. longer

- spinal x-ray?

- spinal examination?

- physical examination?

Please list any other health conditions you have been treated for, or surgery you have had in the last ten years.

FAMILY HEALTH HISTORY: Information about your immediate family members, brothers, sisters, parents, and grandparents will give us a better understanding of your total health picture.

RELATIONSHIP	PRESENT AND PAST HEALTH PROBLEMS

Please mark your areas of pain on the figures below.