Confidential Health Information: All information you supply is confidential. We comply with all federal privacy standards. Please answer all sections completely.
PATIENT INFORMATION
______/_____/______
Today’s Date
______
Your Name Birth date
______
Address City, State, Zip
______
Phone Number Email address
______
Who may we thank for referring you?
Have you ever consulted a chiropractor before? Yes___ No___
If yes, when and whom? ______
Marital status: Single ___ Married ___ Divorced ___ Widowed ______
Spouse’s name (if applicable)
Number of children (with ages): ______
______
Patient’s Occupation Patient’s Employer
______
Primary Care Physician’s Name Last date seen by Primary Care Physician
___ I give my permission to be called by FCoC staff if necessary and to be added to Dr. Miller’s office email list (protected, not sold) and to be sent occasional cards, letters, health information via email or snail mail.
In order to keep operating costs low by not having additional staff, and to pass these savings along to our patients, we do not accept any health insurance, nor do we provide diagnosis codes or insurance forms in this office.
MAJOR COMPLAINT - PLEASE FILL OUT COMPLETELY
1. What is the reason for your visit to our office today:
______
2. When did you first notice your symptoms: ______
3. How severe are your symptoms (from 1-10, 1 being mild, 10 being agonizing): ______
4. Timing of your pain: ___ Constant ___ Comes and goes
5. What does it feel like? ___Numbness ___Tingling ___Stiff ___Dull ___Sharp ___Burning ___Shooting ___Stabbing
6. Is it: ___ Getting Worse ___ Getting Better ___ Staying the Same
7. Does the pain affect or travel to other areas of the body? ______
8. What makes the pain better? ______
What makes the pain worse? ______
9. What have you tried to relieve the symptoms? ______
10. Is there anything else we should know about your current condition? ______
11. How does this condition interfere with your:
Work: ______
Recreation: ______
OTHER HEALTH ISSUES
PLEASE CHECK ANY HEALTH PROBLEMS THAT YOU ARE EXPERIENCING:
___ Headaches ___ Seizures ___ Irregular Mentrual Periods
___ Sinus ___ Heartburn/Reflux ___ Erectile Dysfunction
___ Allergies ___ Constipation ___ Cancer (now or in the past)
___ TMJ ___ Diarrhea ___ Shoulder Pain
___ Asthma ___ Ringing in Ears ___ Elbow Pain
___ ADHD ___ Ear Infections ___ Wrist Pain/Carpal Tunnel
___ Anxiety ___ Thyroid Issues ___ Hip Pain
___ Depression ___ Diabetes ___ Knee Pain
___ High Blood Pressure ___ Infertility ___ Ankle/Foot Pain
___ High Cholesterol ___ Menstrual Cramps ___ Fibromyalgia
Other issues not listed: ______
Major falls, accidents, injuries (please include dates):
______
Surgeries, hospitalizations, joint replacements (please include dates- use back of sheet if necessary):
______
Medicines you are currently taking:
______
HEALTH ASSESSMENT PAGE - PLEASE ANSWER ALL QUESTIONS
ON A REGULAR OR SEMI-REGULAR BASIS, DO YOU (PLEASE CIRCLE ANSWER TO EACH QUESTION):
Drink Caffeine? YES NO
Drink Diet Sodas? YES NO
Make An Effort To Drink Enough Water? YES NO
Smoke Cigarettes? YES NO
Drink Alcohol? YES NO
Eat High Sugar Content Foods? YES NO
Have An Exercise Program? YES NO
Do Yoga? YES NO
Get Regular Massages? YES NO
Get Acupuncture? YES NO
Take Vitamins/Supplements? YES NO
Get At Least 7 Hours Of Sleep Per Night? YES NO
Are Able To Mentally Focus? YES NO
How Many Times Have You Taken Antibiotics In The Last 12 Months?
0 1-2 3-5 6+
How Many Different Medications (Include Over The Counter And Prescription) Do You Take Per Day?
0 1-2 3-5 6+
Would You Say You Are Healthier Today Than You Were 5 Years Ago?
YES NO
Do You Expect That You Will Be Healthier 5 Years From Now Than You Are Today?
YES NO