Client Health History

 

           In order for us to obtain a complete medical history, it is important for you to fill out this form as completely as possible.

This is very important information. Please fill out every item. It is important that you have carefully reviewed every area of this form.

Use the back of these pages for additional information.

 

Client’s Name _____________________________ Date of Birth __________________ Age __________

Sex: Male Female

_______________________________________________

Name of Primary Care (Family) Physician__________________________________________

_________________________________________________________

 

Chief Complaint

 

_____________________________________________________________________

When Did Symptoms Begin? __________________________________________________________________

What Other Treatments Have You Tried? Circle all that apply:

Non-steroid Anti-inflammatory Medications Physical Therapy Chiropractic Care

Acupuncture Surgery Epidural Steroids Pain Management

Other: __________________________________________________________________________________

What Tests Have You Had? Circle all that apply:

MRI Scan CT Scan X-rays EMG by Dr. __________________________________

Current problem is a result of a(n): Circle all that apply:

Car Accident Work Accident Other Accident Other

How Did Accident Occur or Symptoms Begin? ___________________________________________________

__________________________________________________________________________________

 

If yes, please list below. If needed, use the back of this sheet for additional information. No Yes

 MEDICATIONS

Please list all medications that you are currently using. (PLEASE PRINT NEATLY)

Drug

Dose

Frequency (Times Per Day)

Drug

Dose

Frequency (Times Per Day)

 

 

 

 

 

 

MEDICATION ALLERGIES

Are you allergic to ANY medication? No Yes

Are you allergic to X-Ray Contrast No Yes Type of Reaction: ______________________

If yes, please list below.

Name of Medication

Type of Reaction

 

 

 

 

 

NON-MEDICATION ALLERGIES

Do you have any non-medication allergies, such as pollens, dust, food, etc.? No Yes

If yes, please indicate what you are allergic to and type of reaction.

 

Name of Allergen & Type of Reaction

Breathing Dust, Smoke, Fumes or Animals No Yes _______________________________________

____________

Iodine Soaps or Shellfish No Yes ___________________________________________________

Latex No Yes ___________________________________________________

Tape or Adhesives No Yes ___________________________________________________

Other_______________ No Yes ___________________________________________________

 

PAST HEALTH:

Have you ever been diagnosed with any major health problems? Please list.

 

Cancer:

Type ___________________________ No Yes If yes, when?_________________________

 

Problems you were born with:

Type ___________________________ No Yes If yes, when?_________________________

 

Head & Face:

Type ___________________________ No Yes If yes, when?_________________________

 

Eyes, Ears, Nose, Throat and Sinus Problems:

Type ___________________________ No Yes If yes, when?_________________________

 

 

Heart and Blood Vessels:

Heart Attack No Yes If yes, when?_________________________

High Blood pressure No Yes If yes, when?_________________________

Other___________________________ No Yes If yes, when?_________________________

 

Lungs and Respiratory:

Asthma No Yes If yes, when?_________________________

Tuberculosis No Yes If yes, when?_________________________

Other___________________________ No Yes If yes, when?_________________________

 

Stomach and Digestive:

Duodenal ulcer No Yes If yes, when?_________________________

Hepatitis No Yes If yes, when?_________________________

Stomach ulcer No Yes If yes, when?_________________________

Other___________________________ No Yes If yes, when?_________________________

 

Male /Female Health & Urinary Tract:

Are you pregnant? (Female) No Yes If yes, due date? _____________________

Prostate enlargement (Male) No Yes If yes, when?________________________

Renal failure No Yes If yes, when? _______________________

Other___________________________ No Yes If yes, when?________________________

 

Bones, Joints and Muscles:

Type __________________________ No Yes If yes, when?________________________

 

Skin & Breasts:

Type __________________________ No Yes If yes, when?________________________

 

Brain and Nervous System:

Type __________________________ No Yes If yes, when?________________________

 

Mental & Emotional:

Type __________________________ No Yes If yes, when?________________________

 

Glands, Hormones, and Sugar Control:

Diabetes No Yes If yes, when?________________________

Thyroid deficiency No Yes If yes, when?________________________

Thyroid excess No Yes If yes, when?________________________

Blood & Lymph Node problems:

Type __________________________ No Yes If yes, when?________________________

 

Allergies, Immune & Infectious Problems:

Hepatitis No Yes If yes, when?_______________________

Rheumatoid Arthritis No Yes If yes, when?_______________________

Other serious Infection___________________ No Yes If yes, when?________________________

 

Have you ever been diagnosed with any other major health problem not listed above? No Yes

If yes, please list diagnosis and year the diagnosis was made. ____________________________________

___________________________________________

______________________________________________________________

__________________________________________________________________

_______________________________________________________________

SURGERIES AND HOSPITALIZATIONS

 

Have you ever had any problems with anesthesia (being numbed or put to sleep)? No Yes

If yes, please list what sort of problems.

__________________________________________________________________________________________

Have you ever had surgery? No Yes

If yes, list any surgeries and when they were done. _____________________________________________________

___________________________

__________

Have you been hospitalized for a medical problem before? No Yes

If yes, list hospitalizations, the reason for admission and the date. __________________________________________

________________________________________________

__________________________________________________________________________________________

 SERIOUS INJURIES

Have you ever had a serious injury, such as head, neck, back, or other injury? No Yes

If yes, list and describe the type of injury and when it occurred.

____________________________________________________________________________________________

_______________________________________________________________________________________

 

FAMILY HISTORY

If Deceased Circle Mother Father

Cause of Death ____________________ ____________________

 

Heart and Blood Vessels:

Heart Disease Mother Father Brother Sister

High Blood Pressure Mother Father Brother Sister

Lungs and Respiratory:

Asthma Mother Father Brother Sister

Lung Cancer                 Mother Father Brother Sister

Breast Cancer            Mother Father Brother Sister

Brain and Nervous System:

Dementia                      Mother Father Brother Sister

Stroke                          Mother Father Brother Sister

Aneurysm                     Mother Father Brother Sister

Brain Tumor                 Mother Father Brother Sister

Spine Problems            Mother Father Brother Sister

 

Diabetes                      Mother Father Brother Sister

Thyroid Disease                     Mother Father Brother Sister

Blood & Lymph Node problems:

Anemia                                     Mother Father Brother Sister

Bleeding/clotting problem          Mother Father Brother Sister

Other________________       Mother Father Brother Sister

 

SOCIAL HISTORY

Circle here if you are retired.

What is or was your occupation? ____________________________________________

What is the highest level of education you have had? _____________________________

Marital Status: Single Married Divorced Widowed

Do you have Children? No Yes How many? _________________________

Do you smoke? Yes, I’ve smoked __________ packs of cigarettes per day for ____________years.

Yes, I smoke cigars or pipe.

No, I have never smoked.

No, I quit _______ years ago. At that time I was smoking ________ packs per day for ________ years.

Do you drink alcohol? Yes What kind and how much? ________________________________________

No, never No, but I used to. At that time I was drinking ________________ per day for ______ years.