Patient Information Form Page 2
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4Bakke Chiropractic Clinic
HEALTH HISTORY FORM
Name: ______________________________ Date of Birth: ___________ Date: __________ Case#: __________
Race: ___________
Language: ___________
Ethnicity: Hispanic / Non-Hispanic
Family Physician: _________________________ Date of last physical exam: ______________
Sex: M F Weight: ______ Height: ____feet ____inches Age: _______
Mark the following conditions you or your family members have had.
Self
Father
Mother
Brother/
Self
Father
Mother
Brother/
Sister
Sister
Medical Conditions
Alcoholism
Foot Problems
Anemia
Heart Disease
Appendicitis
Miscarriage
Cancer
Polio
Diabetes
Stroke
Eczema
Ulcers
Emphysema
Multiple Sclerosis
Goiter
Rheumatic Fever
Gout
Tuberculosis
Check the box for any of the following that you have currently or had recently.
General
Gastro-Intestinal
Cardio-Vascular
Skin
Allergy
Distention/pain
Chest pain
Bruises easily
Convulsions
over stomach
High blood pressure
Dryness
Dizziness
Gall Bladder trouble
Low blood pressure
Skin eruptions
Fainting
Constipation
Rapid heart beat
Rash
Nerve Problems
Diarrhea
Slow heart beat
Genito-Urinary
Numbness
Hemorrhoids
Hardening
Frequent urination
Headache
Eyes/Ears/Nose/Throat
of arteries
Painful urination
Asthma
Poor circulation
Inability to control
Muscle/Joint
Colds
Swelling of ankles
bladder
Arthritis
Sinus Infection
Varicose veins
Kidney infection
Neck
Nosebleeds
Respiratory
Kidney stones
pain/stiffness
Earache
Chest pain
Prostate trouble
Mid-back pain
Ear Noises/Ringing
Chronic cough
Blood in urine
Low back pain
Deafness
Difficult breathing
Bed-wetting
Sciatica
Eye conditions
Spitting up phlegm
Swollen joints
Spitting up blood
HAVE YOU EVER:
HABITS:
Had Chiropractic care
Alcohol Use:
Rare
Occasional
Regular
Been knocked unconscious
Coffee
Used a crutch or other support
Smoking:
Previous
Current
Never
Been treated for a spine or nerve disorder
Smokeless tobacco
Had a fractured bone
Illicit drugs
Been hospitalized for other than surgery
Ever had surgery (please list) ___________________________________________________________
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