Confidential Patient Health Profile For The Pregnant Patient Form Page 2

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What makes it better?
___________________________________________________________________________________________________
Does the pain refer anywhere (leg, buttock, chest etc.)? ____________________________________________
Is this condition getting progressively worse?
Yes
No
Constant
Intermittent
If you are experiencing pain, how would you describe it? (Dull, sharp, shooting etc.)
___________________________________________________________________________________________________
Is this condition interfering with your
Work
Sleep
Daily Routine
Other__________________
On a scale of 1 to 10, rate your stress levels. (0 = none, 10 = extreme)
Occupational ________ Personal _________
How long has it been since you really felt well? ______________________________________________________
Has there been a medical diagnosis of your complaint?
Yes
No If “yes”, list the Doctor’s name
and the diagnosis: _________________________________________________________________________________
Please check all that apply to your current/past medical history:
____ Neck Pain/Stiffness
____ Nose Bleeds
____ Increased Appetite
____ Mid Back Pains
____ Sinus Problems
____ Excess Gas
____ Low Back Pain
____ Ringing in Ears
____ Vomiting
____ Pins/Needles in Arms
____ Hearing Trouble
____ Diarrhea/ Constipation
____ Numbness in Fingers
____ Chronic Sore Throats
____ Hemorrhoids
____ Pins/Needles in Legs
____ Difficulty Breathing
____ Painful urination
____ Numbness Legs/Toes
____ Asthma
____ Frequent Urination
____ Headaches
____ Allergies
____ Bedwetting
____ Fatigue
____High Blood Pressure
____ Prostate Problems
____ Weakness
____High Cholesterol
____ Impotence
____ Insomnia
____ Chest Pain
____ Sterility
____ Fever
____ Heart Palpitations
____ Miscarriage
____ Chills
____ Heart Murmur
____ Painful Menstruation
____ Weight Change
____ Heart Burn/Acid Reflux
____ Irregular Periods
____ Skin Rashes
____ Varicosities
____ Menopause
____ Bruise Easily
____ Swollen Extremities
____ Anxiety
____ Dizziness
____ Lumps in Breast
____ Depression
____ Fainting
____ Breast Discharge
____ Memory Loss
____ Seizures
____ Abdominal Pain
____ Other…
____ Vision Trouble
____ Decreased Appetite
List surgeries, broken bones, and major illnesses (including childhood): _______________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Have you ever been hospitalized?
Yes
No Reason: ___________________________________________
How healthy is your family? Are there any conditions like diabetes, cancer or heart disease on your
mother or father’s side? If so explain: _______________________________________________________________
___________________________________________________________________________________________________
Have you ever been in an auto accident?
Never
Past Year
Past 5 Years
Over 5 Years
Is there or might there be a lawyer involved?
Yes
No
Description of accident:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Is your insurance company involved?
Yes
No

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