Synergyhealthassociates.com - Health History Form

Confidential Patient Health Record
DATE

MonthDayYear
Date
iD. NO.
PERSONAL HISTORY
Name

First NameLast Name
Address

Street Address

Street Address Line 2

City/SuburbState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Birth Date

MonthDayYear
Date
Age
Gender
Cell Phone
Please enter a valid phone number.
E-mail Address
example@example.com
Social Security #*
Driver's License Number
Marital Status
Business Employer
Type of Work
Business Phone
Please enter a valid phone number.
Name of Spouse
Spouse's Social Security #
Spouse’s Employer
Business Phone
Please enter a valid phone number.
Type of Work
Referred To This Office By
Name and Ages of Children
Name and Number of Emergency Contact
Relationship
Who Is Responsible For Your Bill, You and
CURRENT HEALTH CONDITION
Unwanted Health Condition
Other Doctors Seen For This Condition

YesNo
Who?
Type of Treatment
Results
When Did This Condition Begin?
Has This Condition Occurred Before?

YesNo
Is Condition
Date of Accident

MonthDayYear
Date
Time of Accident
Have You Made A Report of Your Accident To Your Employer

YesNo
Drugs You Now Take
Do You Wear A Shoe Lift?

YesNo
Do You Suffer From Any Condition Other Than That Which You Are Now Consulting Us?
PAST HEALTH HISTORY

Please Check and Describe
Major Surgery/Operations
Major Accident or Falls
Hospitalization (Other Than Above)
Previous Chiropractic Care

YesNo
If yes, Doctor’s Name & Approximate Date of Last Visit
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.
CHECK ANY OF THE FOLLOWING DISEASES YOU HAVE HAD

PneumoniaRheumatic FeverPolioTuberculosisWhooping CoughMeaslesMumpsSmall PoxChicken PoxDiabetesCancerHeart DiseaseThyroidInfluenzaPleurisyArthritisEpilepsyMental DisordersLumbagoEczemaOther
INTAKE

CoffeeTeaAlcoholCigarettes
Have you been tested HIV positive?

YesNo
CHECK ANY OF THE FOLLOWING YOU HAVE HAD THE PAST 6 MONTHS
MUSCULO-SKELETAL CODE

Low Back PainPain Between ShouldersNeck PainArm PainJoint Pain/StiffnessWalking ProblemsDifficult Chewing/Clicking JawGeneral Stiffness
NERVOUS SYSTEM CODE

NervousNumbnessParalysisDizzinessForgetfulnessConfusion/DepressionFaintingConvulsionsCold/TingIing ExtremitiesStress
GENERAL CODE

FatigueAllergiesLoss of SleepFeverHeadaches
GASTRO-INTESTINAL CODE

Poor/Excessive AppetiteExcessive ThirstFrequent NauseaVomitingDiarrheaConstipationHemorrhoidsLiver ProblemsGall Bladder ProblemsWeight TroubleAbdominal CrampsGas/Bloating After MealsHeartburnBlack/Bloody StoolColitis
GENITO-URINARY CODE

Bladder TroublePainful/ Excessive UrinationDiscolored Urine
C-V-R CODE

Chest PainShort BreathBlood Pressure ProblemsIrregular HeartbeatHeart ProblemsLung Problems/CongestionVaricose VeinsAnkle SwellingStroke
EENT CODE

Vision ProblemsDental ProblemsSore ThroatEar AchesHearing DifficultyStuffed Nose
MALE/FEMALE CODE

Menstrual IrregularityMenstrual CrampsVaginal Pain/InfectionBreast Pain/LumpsProstate/SexuaI DysfunctionOther
FEMALES ONLY
When was your last period?
Are you pregnant?

YesNoNot Sure
FAMILY HISTORY

The following members have a same or similar problem as I do.

	Problem
Mother
Father
Brother
Sister
Spouse
Child

Patient Accepted
Should be Empty:

Confidential Patient Health Record

PERSONAL HISTORY

CURRENT HEALTH CONDITION

PAST HEALTH HISTORY

CHECK ANY OF THE FOLLOWING YOU HAVE HAD THE PAST 6 MONTHS

FEMALES ONLY

FAMILY HISTORY