Confidential Patient Health Record

Dr. Ian Rainey, D. C.

545 Metro Place S. · Suite 100 · Columbus, OH 43016 · (614) 987-8390

Confidential Patient Health Record - PERSONAL HISTORY

Date: _____________ Family Doctor: _________________________ Who referred you to this office:_____________________

Last Name:______________________ First Name:____________________ Middle Initial: ____

Date of Birth:_________________ Age:_______ Gender: ___M ___F Social Security #:_____________________________

Marital Status: Married/Single/Widowed/Divorced/Separated

Street Address:___________________________________________________________________________________________

City:__________________________ State:________ Zip Code:_________________

Home Phone:___________________________ Cell Phone :___________________________ Preferred Phone _____________

Employment Status: ____________________________________ Professional Title:___________________________________

Email:______________________________________ Employer Name & Phone #: _____________________________________

Name of Emergency Contact:_______________________ Relationship:______________ Phone Number__________________

Name of Spouse (if applicable):________________________ Spouse’s Employer:___________________________________

Names and Ages of Children________________________________________________________________________________

Who is Responsible for your bill: You and ___Cash/Health Savings Account ___Health Insurance __Auto Insurance

Health Insurance Company: ________________________________ Insurance ID #:___________________________________

If insurance is under a different name: ____________________________________ Date of Birth: _________________________

CURRENT HEALTH CONDITION

Purpose of this appointment:_______________________________________________________________________________

Other Doctors seen for this condition: ____Yes ___No Who?_____________________________________________

Type of Treatment:________________________________ Results:___________________________________________

When did this Condition begin?______________________ Has this condition occurred before? ___Yes ___No

Is Condition: ___Job Related ___Auto Accident ___Home Injury ___Fall ___Other:______________________________

Date of Accident:__________________________________ Time of Accident:___________________________________

Have you made a report of your Accident to your Employer: ___Yes ___No Insurance Company ___Yes ___No

Drugs you now take: ___Nerve Pills ___Pain Killers/Muscle Relaxers ___Blood Pressure Medicine ___Sleep Aids

___Insulin ___Other____________________________________________________________________________________

Do you wear a shoe lift? ___Yes ___No Have you ever worn a spinal brace? ___Yes ___No

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: ___Appendectomy ___Tonsillectomy ___Gall Bladder ___Hernia ___Back Surgery

___Broken Bones ___Other______________________________________________________________________________

Smoker? Current/Former/Never If yes, explain:_____________________________________________________________

Major Accident or Falls:___________________________________________________________________________________

______________________________________________________________________________________________________

Hospitalization (Other than Above):_________________________________________________________________________

______________________________________________________________________________________________________

Previous Chiropractic Care: ___None ___Doctor’s Name & Approximate Date of Last Visit: ________________________

PATIENT INTAKE FORM

Patient Name: _____________________________ Date: _______________

1. Is today's problem caused by: ___Auto Accident ___ Workman's Compensation ___ Other

If “Other”, please list cause _______________________________________________

Chief Complaint: Indicate on the drawings below where you have pain/symptoms

2. What concerns you the most about your problem; what does it prevent you from doing? Please specify each symptom next to each selection (ex: knee/back, neck, etc)

□ It could be Serious □ It isn’t going away

□ It is getting worse □ It is affecting daily activities

3. How would you describe the type of pain? Please specify each symptom next to each selection (ex: knee/back, neck, etc)

□ Sharp □ Numb

□ Dull □ Tingly

□ Diffuse □ Sharp with motion

□ Achy □ Shooting with motion

□ Burning □ Stabbing with motion

□ Shooting □ Electric like with motion

□ Stiff □ Other:___________________

4. How often do you experience your symptoms? Please specify each symptom next to each selection (ex: knee/back, neck, etc)

□ Constantly (76-100% of the time) □ Occasionally (26-50% of the time)

□ Frequently (51-75% of the time) □ Intermittently (1-25% of the time)

5. Using a scale from 0-10 (10 being the worst), how would you rate your problem? Please specify each area of pain next to each selection (ex: knee,back, neck, etc)

0 1 2 3 4 5 6 7 8 9 10 (Please circle)

6. How are your symptoms changing with time? Please specify each symptom next to each selection (ex: knee/back, neck, etc)

□ Getting Worse □ Staying the Same □ Getting Better

7. Do you consider this problem (s) to be severe?

□ Yes □ Yes, at times □ No

8. What aggravates your problem? Please specify each area of pain next to each selection (ex:back, neck, etc)

□ Standing □ Sitting

□ Walking □ Sleeping

□ Driving □ Other ___________________________________

9. What makes the pain feel better?

□ Rest □ Heat

□ Ice □ Pain Medications

□ Activity □ Other ___________________________________

10. Who else have you seen for your problem?

□ Chiropractor □ Neurologist □ Primary Care Physician

□ ER physician □ Orthopedist □ Other:_____________

□ Massage Therapist □ Physical Therapist □ No one

11. How long have you had this problem? Please specify each symptom next to each selection (ex: knee/back, neck, etc) _________________________________________________________________

12. How much has the problem interfered with your work? Please specify each symptom:

□ Not at all □ A little bit □ Moderately □ Quite a bit □ Extremely

13. How much has the problem interfered with your social activities? Please specify each symptom:

□ Not at all □ A little bit □ Moderately Quite a bit □ Extremely

14. What is your: Height___________ Weight _____________ Date of Birth ___________

15. How would you rate your overall Health?

□ Excellent □ Very Good □ Good □ Fair □ Poor

16. What type of exercise do you do?

□ Stenuous □ Moderate □ Light □ None

17. How do you want chiropractic to change your life? ______________________________________________________________________________________

18. What things are you unable to do that you would like to be able to do (i.e. pick up grand children, comb your hair, tie your shoes, have more energy)?

1.) __________________________________________________________

2.) __________________________________________________________

3.) __________________________________________________________

19. Indicate if you have any immediate family members with any of the following:

□ Rheumatoid Arthritis □ Diabetes □ Lupus

□ Heart Problems □ Cancer □ ALS

20. For each of the conditions listed below, place a check in the "past" column if you have had the condition in the past. If you presently have a condition listed below, place a check in the "present" column.

Past Present Past Present Past Present

□ □ Headaches □ □ High Blood Pressure □ □ Diabetes

□ □ Neck Pain □ □ Heart Attack □ □ Excessive Thirst

□ □ Upper Back Pain □ □ Chest Pains □ □ Frequent Urination

□ □ Mid Back Pain □ □ Stroke □ □ Smoking/Tobacco Use

□ □ Low Back Pain □ □ Angina □ □ Drug/Alcohol Dependance

□ □ Shoulder Pain □ □ Kidney Stones □ □ Allergies

□ □ Elbow/Upper Arm Pain □ □ Kidney Disorders □ □ Depression

□ □ Wrist Pain □ □ Bladder Infection □ □ Systemic Lupus

□ □ Hand Pain □ □ Painful Urination □ □ Epilepsy

□ □ Hip Pain □ □ Loss of Bladder Control □ □ Dermatitis/Eczema/Rash

□ □ Upper Leg Pain □ □ Prostate Problems □ □ HIV/AIDS

□ □ Knee Pain □ □ Abnormal Weight Gain/Loss

□ □ Ankle/Foot Pain □ □ Loss of Appetite For Females Only

□ □ Jaw Pain □ □ Abdominal Pain □ □ Birth Control Pills

□ □ Joint Pain/Stiffness □ □ Ulcer □ □ Hormonal Replacement

□ □ Arthritis □ □ Hepatitis □ □ Pregnancy

□ □ Rheumatoid Arthritis □ □ Liver/Gall Bladder Disorder

□ □ Cancer □ □ General Fatigue

□ □ Tumor □ □ Muscular Incoordination

□ □ Asthma □ □ Visual Disturbances

□ □ Chronic Sinusitis □ □ Dizziness

□ □ Other:____________________________

21. List all prescription medications you are currently taking (we can make a copy):

______________________________________________________________________________________

22. List all of the over-the-counter medications you are currently taking (we can make a copy):

______________________________________________________________________________________

23. What activities do you do at work? Please check the appropriate boxes.

□ Sit: □ Most of the day □ Half the day □ A little of the day

□ Stand: □ Most of the day □ Half the day □ A little of the day

□ Computer work: □ Most of the day □ Half the day □ A little of the day

□ On the phone: □ Most of the day □ Half of the day □ A little of the day

□ Drives: □ Most of the day □ Some of the day □ A little of the day

□ Activity: □ Performs manual labor □ Reads a lot □ Travels frequently

24. What activities do you do outside of work? (ex: Walk, Run, Swim, Garden, Tennis, Lift weights)

______________________________________________________________________________________

25. Have you had significant past trauma? List date and trauma type: □ No □ Yes

______________________________________________________________________________________

26. Anything else pertinent to your visit today? If so, please list in detail: ______________________________________________________________________________________

______________________________________________________________________________________

27. Do you attest that the above information is accurate and complete to the best of your ability? □ Yes □ No

27. Patient Signature________________________________________ Date:____________________