Handley Chiropractic Clinic Patient Entrance Form (Page 3 of 5) in pdf

HANDLEY CHIROPRACTIC CLINIC

Dr. Leonard Handley, D.C.

PATIENT ENTRANCE FORM

727 Gardiners Road | Kingston, ON K7M 3Y5

(613) 384-1008 ●

PAST MEDICAL HISTORY:

Please check the appropriate box for any of the following symptoms that you currently have or have previously had.

O = Occasional F = Frequent C = Constant

GENERAL

EYES/EARS/NOSE/THROAT, continued

SKIN

  



allergy

sinus infections

boils

  



chills

enlarged glands

bruise easily

  



convulsions

enlarged thyroid

hives/allergies

  



dizziness

sore throats

itching

  



fainting

tonsillitis

skin rash

  



fevers

eye pain

varicose veins

  



headaches

failing vision

  



loss of sleep

far sighted

GASTROINTENSTINAL

  



nervousness

gum trouble

bed wetting

  



depression

hay fever

blood in urine

  



neuralgia

hoarseness

frequent urination

  



numbness

nasal obstruction

loss of urine control

  



sweats

near sighted

kidney infection

  



loss of weight

nosebleeds

painful urination

  



tremors

prostate trouble



CARDIOVASCULAR

pus in urine



MUSCLE & JOINT

vomiting

smell of urine

  



arthritis

vomiting blood

  



bursitis

rapid heart beat

PAIN/NUMBNESS IN

  



foot trouble

slow heart beat

shoulders

  



hernia

swelling of ankles

arms

  



low back pain

hardening of arteries

hands

  



neck pain

high blood pressure

hips

  



neck stiffness

low blood pressure

legs

  



pain between shoulders

pain over heart

knees



poor circulation

ankles



RESPIRATORY

pain over heart

feet

  



chest pain

tail bone

  



chronic cough

GASTROINTENSTINAL

sciatica

  



difficulty breathing

excess hunger

swollen joints

  



spitting blood

burping or gas

  



throat phlegm

liver trouble

FOR WOMEN ONLY

  



wheezing

colitis

cramps



colon trouble

heavy flow



EYES/EARS/NOSE/THROAT

constipation

light flow

  



colds

diarrhea

irregular cycle

  



crossed eyes

distension of abdomen

painful cycle

  



deafness

stomach pain

discharge

  



dental decay

gall bladder trouble

sore breasts

  



asthma

hemorrhoids

Menopausal:

YES

  



ear aches

intestinal worms

Last menstruation: ..................................

  



ear discharges

jaundice

Pregnant:

YES

  



ear noises

poor appetite

Date Due: ...............................................

Page 3 of 5

C:/My Documents/CLINIC FILES/CLINIC Forms/HANDLEY Patient Entrance.doc [last updated on 11-NOV-2010]

Handley Chiropractic Clinic Patient Entrance Form Page 3

Related Articles

Related forms

Related Categories