Type of Care form

Confidential Patient Health Record
DATE

Month Day Year
Date
I.D. NO.
PERSONAL HISTORY
City
Name
Home Phone

Area Code Phone Number
Address

Address

Street Address Line 2

State

Zip Code
Cell Phone

Area Code Phone Number
Birth Date

Month Day Year
Date
E mail Address
example@example.com
Age
Sex

M F
Married

Social Security # Check One:
Married

Single
Social Security #
Driver's License Number
Business Employer: Business Phone

Area Code Phone Number
Business Employer
Single

Widowed
Widowed

Divorced
Divorced

Separated
Type of Work
Name of Spouse Spouse's Employer Type of Work Referred To This Office By: Name and Number of Emergency Contact: Who Is Responsible For Your Bill, You and Personal Health Insurance (Name) Insured Person's Name

Spouse Workers' Comp.
Name of Spouse
Spouse's Employer
Spouse's Social Security #
Type of Work
Referred To This Office By
Spouse's Social Security # Business Phone Name and Ages of Children

Area Code Phone Number
Name and Ages of Children
Name and Number of Emergency Contact
Relationship

Name of Spouse Spouse's Employer Type of Work Referred To This Office By: Name and Number of Emergency Contact: Who Is Responsible For Your Bill, You and Personal Health Insurance (Name) Insured Person's Name Blood Pressure Medicine
Relationship

Auto Insurance
Relationship

Medicare Medicaid
Relationship
Insured Person's Name
Personal Health Insurance (Name)
Health Card

Time of Accident: No CURRENT HEALTH CONDITION Who? Date of Birth
Health Card #
Date of Birth

Yes No
Unwanted Health Condition
CURRENT HEALTH CONDITION

Yes No
Date of Birth

Month Day Year
Date
Type of Treatment
Who?

Results:
Who?
When Did This Condition Begin?
Has This Condition Occurred Before? Fall Other:
Results
Date of Accident

Month Day Year
Date
Time of Accident
Other
Blood Pressure Medicine

Auto Accident Home Injury Date of Accident: Have You Made A Report of Your Accident To Your Employer:Yes Drugs You Now Take:Nerve Pills Pain Killers/Muscle Relaxers Insulin Other Unwanted Health Condition Other Doctors Seen For This Condition: Type of Treatment: When Did This Condition Begin? Is Condition: Job Related Has This Condition Occurred Before? Fall Other:
Do You Wear A Shoe Lift? Do You Suffer From Any Condition Other Than That Which You Are Now Consulting Us?

Yes No
Do You Suffer From Any Condition Other Than That Which You Are Now Consulting Us?
Please Check and Describe: Major Surgery/Operations: Broken Bones Other Major Accident or Falls:
PAST HEALTH HISTORY

Appendectomy
PAST HEALTH HISTORY

Tonsillectomy
Appendectomy

Please Check and Describe: Major Surgery/Operations: Broken Bones Other Major Accident or Falls:
Tonsillectomy

Gall Bladder Hernia Back Surgery
Hospitalization {Other Than Above):
Previous Chiropractic Care

None
Previous Chiropractic Care

Doctor's Name & Approximate Date of Last Visit
CHECK ANY OF THE FOLLOWING DISEASES YOU HAVE HAD:
Pneumonia

Pneumonia Rheumatic Fever Polio Tuberculosis Whooping Cough Anemia Measles Mumps Small Pox Chicken Pox Diabetes Cancer Heart Disease Thyroid CHECK ANY OF THE FOLLOWING DISEASES YOU HAVE HAD: Influenza Pleurisy Arthritis Epilepsy Mental Disorders Lumbago Eczema Below are a list of diseases which may seem unrelated to the purpose of your appointment. However, these questions must be answered carefully as these problems can affect your overall course of care. Coffee Tea Alcohol Cigarettes White Sugar INTAKE Coffee Chicken Pox Arthritis Tuberculosis Tea Diabetes Whooping Cough Epilepsy Alcohol Cancer Anemia Mental Disorders Cigarettes Heart Disease Measles Lumbago White Sugar Thyroid Eczema
Yes

Yes No
FEMALES ONLY:
When was your last period?
Heartburn

Yes Have you been tested HIV positive? Are you pregnant? YesNo Not Sure No When was your last period? FEMALES ONLY: No Not Sure GENITO-URINARY CODE Bladder Trouble Painful/Excessive Urination Discolored Urine General Stiffness
Are you pregnant? YesNo

Low Back Pain Pain Between Shoulders Neck Pain Arm Pain Joint Pain/Stiffness Walking Problems Difficult Chewing/Clicking Jaw General Stiffness Gas/Bloating After Meals Heartburn Black/Bloody Stool Colitis CHECK ANY OF THE FOLLOWING YOU HAVE HAD THE PAST 6 MONTHS: MUSCULO-SKELETAL CODE
Bladder Trouble

Bladder Trouble Painful/Excessive Urination Discolored Urine
Nervous

Nervous Chest Pain Numbness Short Breath Paralysis Blood Pressure Problems Dizziness Irregular Heartbeat Forgetfulness Heart Problems Confusion/Depression Lung Problems/Congestion Fainting Varicose Veins Convulsions Ankle Swelling Cold/Tingling Extremities Stress
Stroke

Stroke Vision Problems
Fatigue

Fatigue Allergies Loss of Sleep Fever Headaches
Dental Problems

Dental Problems Sore Throat Ear Aches Hearing Difficulty Stuffed Nose
Poor/Excessive Appetite

Poor/Excessive Appetite Excessive Thirst Frequent Nausea Vorniting Diarrhea Constipation Remorrhoids Menstrual Irregularity Menstrual Cramps Vaginal Pain/Infection Breast Pain/Lumps Prostate/Sexual Dysfunction Other Problems GASTRO-INTESTINAL CODE MALE/FEMALE CODE The following members have a same or similar problem as I do: Mother Father Brother Sister Spouse Child Vision Problems Dental Problems Sore Throat Ear Aches Hearing Difficulty Stuffed Nose FAMILY HISTORY Headaches EENT CODE Please outline on the diagram the area of your discomfort Fatigue Allergies Loss of Sleep Fever Nervous Numbness Paralysis Dizziness Forgetfulness Confusion/Depression Fainting Convulsions Cold/Tingling Extremities Stress Chest Pain Short Breath Blood Pressure Problems Irregular Heartbeat Heart Problems Lung Problems/Congestion Varicose Veins Ankle Swelling Stroke GENERAL CODE C-V-R CODE NERVOUS SYSTEM CODE Liver Problems Gall Bladder Problems Weight Trouble Abdominal Cramps Spouse Liver Problems Child Gall Bladder Problems Weight Trouble Abdominal Cramps
ANALYSIS
DO NOT WRITE BELOW THIS LINE
DIAGNOSIS:
Doctor's Signature

Clear
Patient Accepted

Yes No Referred
Should be Empty:

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PERSONAL HISTORY

CHECK ANY OF THE FOLLOWING DISEASES YOU HAVE HAD:

FEMALES ONLY:

DO NOT WRITE BELOW THIS LINE

DIAGNOSIS: