3 Park Place, Suite B, Swansea, Illinois 62226 618.236.3600
Personal Information
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State in which injury occurred
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How Can We Help You?
What would you like us to address on this visit? Please check all that apply:
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General Wellness
Neck Pain
Hip Pain
Back Pain
Infant Colic
Shoulder Pain
Carpal Tunnel
Numbness/Tingling
Headaches
Scoliosis
Arthritis
Sciatica
TMJ Problem
Weight
Restricted Motion
Muscle Aches
Fatigue
Cold/Sinus
Allergies
Ear Infection
Dizziness
ADD/ADHD
Disk Problem
Fibromyalgia
Other
Give a brief description of the problem:
When did it start?
Have you consulted or treated with anyone else?
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No
Who/When?
Please list any treatment, testing, and diagnostics:
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Health History Questions
Please check all that apply to your current or past health status. Use the "Other" box below for anything not listed, or to include additional information.
General
Alcoholism
Allergies
Anemia
Appendicitis
Asthma
Bronchitis
Cancer
Cold Sores
Depression
Diabetes
Dizziness
Eczema
Edema
Emphysema
Epilepsy
Fainting
Fatigue
Fever
Headaches
Heart Disease
Hepatitis
Herpes
HIV / AIDS
Loss of Sleep
Mental Illness
Multiple Sclerosis
Nervousness
Osteoporosis
Pace Maker
Polio
Stroke
Thyroid Disease
Tuberculosis
Tremors
Ulcer
Weight Loss/Gain
Other
Muscle / Joint
Arthritis
Bursitis
Foot Trouble
Muscle Weakness
Lower Back Pain
Neck Pain
Mid Back Pain
Joint Pain
Other
Skin
Boils
Bruising
Dryness
Hives
Itching
Rash
Varicose Veins
Other
Eye,Ear, Nose, Throat
Colds
Deafness
Ear Ache
Eye Pain
Gum Trouble
Hoarseness
Nasal Obstruction
Nose Bleeds
Ringing Ears
Sinus Infection
Sore Throat
Tonsillitis
Vision Problems
Other
Gastrointestinal
Abdominal Pain
Bloody / Tarry Stool
Colitis / Chron"s
Constipation
Diarrhea
Diverticulosis
Bloated Abdomen
Gallbladder Trouble
Hernia
Hemorrhoids
Jaundice
Liver Trouble
Nausea
Vomiting
Vomiting Blood
Other
Genitourinary
Bed Wetting
Bladder Infection
Blood in Urine
Kidney Infection
Kidney Stones
Prostrate Trouble
Pus in Urine
Stress Incontinence
Other
Cardiovascular
High Blood Pressure
Low Blood Pressure
Hardening of the Arteries
Irregular Pulse
Pain in Chest
Palpitations
Poor Circulation
Rapid Heart Beat
Slow Heart Beat
Swelling of Ankles
Other
Respiratory
Chest Pain
Chronic Cough
Difficulty Breathing
Hay Fever
Shortness of Breath
Spitting Up Blood
Wheezing
Other
Women Only
Congested Breasts
Hot Flashes
Lump in Breast
Menopause
Vaginal Discharge
Other
Are you pregnant?
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Yes
No
Not Sure
Due Date
Family History
Alcoholism
Anemia
Arteriosclerosis
Arthritis
Asthma
Bleed Easily
Cancer
Diabetes
Emphysema
Epilepsy
Glaucoma
Heart Disease
High Blood Pressure
High Cholesterol
Multiple Sclerosis
Osteoporosis
Stroke
Thyroid Disease
Other
Please list any of the following that you have experienced, even if you think they were minor. Include dates when applicable.
Car Accidents
Slip, Trip, or Fall
Work Injuries
Please list ALL medications (prescription and over-the-counter) and nutritional supplements that you have taken in the past 6 months:
Prescription Medications
Over-the-Counter
Nutritional Supplements
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