waterburychiropracticwellness.com - Patient Health History

HEALTH HISTORY QUESTIONNAIRE
PATIENT NAME
DATE

MonthDayYear
Date
Below is a list of conditions which may seem unrelated to the purpose of your appointment. However, these questions must be answered carefully as these problems can affect your overall diagnosis, treatment plan and possibility of being accepted for care.
CHECK ANY OF THE FOLLOWING DISEASES YOU HAVE HAD:

AlcoholismAnemiaAppendicitisArthritisAsthmaCancerChicken PoxCOPDDiabetesDiphtheriaEczemaEpilepsyGoiterHeart DiseaseHepatitisInfluenzaRheumatic FeverLumbagoMalariaScarlet FeverMeaslesShinglesMental DisorderMumpsPleurisyPneumoniaPolioSleep ApneaSmall PoxTuberculosisTyphoid FeverWhooping Cough
CHECK ANY OF THE FOLLOWING YOU HAVE OR HAVE HAD IN THE PAST 6 MONTHS:
MUSCULO-SKELETAL CODE

Arm PainDifficult Chewing / Clicking JawJoint Pain / StiffnessLow Back PainNeck PainPain Between ShouldersWalking Problems
NERVOUS SYSTEM CODE

Cold / Tingling ExtremitiesConfusion / DepressionConvulsionsDizzinessFainting ForgetfulnessNumbnessParalysis
GASTO-NTESTINAL CODE

Abdominal CrampsBlack / Bloody StoolsColitisConstipationDiarrheaExcessive ThirstFrequent NauseaGall Bladder ProblemsGas / Bloating After MealsHeartburHemorrhoidsLiver TroublePoor / Excessive AppetiteVomiting Weight Trouble
GENERAL CODE

AllergiesFeverLoss of Sleep
GENITO-URINARY CODE

Bladder TroubleDiscolored UrinePainful/Excessive Urination
C-V-R CODE

A-FibAnkle SwellingBlood Pressure ProblemsChest PainHeart ProblemsIrregular HeartbeatLung Problems / CongestionShort BreathVaricose Veins
EENT CODE

Dental ProblemsEar AchesHearing DifficultySore ThroatStuffy NoseVision Problems
MALE/FEMALE CODE

Breast Pain / LumpsMenstrual CrampingMenstrual IrregularityVaginal Pain / InfectionsProstate / Sexual DysfunctionGenital Herpes
FEMALES ONLY:
When was your last period?
Are you pregnant?

YesNoMaybe
Please Outline on the diagram area of your discomfort. Draw on the image
Should be Empty:

HEALTH HISTORY QUESTIONNAIRE

FEMALES ONLY: