Medical History Intake Form Page 4
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8Please mark each that applies to your Daily Activities:
How often do you have to stop activities
Has difficulty climbing stairs.
and sit or lie down to control your
symptoms?
Stays at home most of the time due to the problem.
Several times a day
Changes position frequently to try and get comfortable.
Occasionally
Walks more slowly than usual because of the problem.
Approximately once per day
Does not do jobs around the house because of the problem.
Never
Has to use handrails to get up stairs, etc.
All day
Has to lie down and rest frequently due to the problem.
Has to hold onto something to sit or stand from a chair.
SOCIAL HISTORY
Has to get other people to do things for you.
Single
Has difficulty getting dressed due to the problem.
Married
Can only stand for short periods due to the problem.
Divorced
Has difficulty bending or kneeling due to the problem.
Children
How many? _________
Has difficulty turning over in bed due to the problem.
Has a loss of appetite due to the problem.
Smoker
Can only walk short distances because of the problem.
Non-smoker
Drinks alcohol
Has difficulty sleeping because of the problem.
Do not drink alcohol
Has to get dressed with someone’s help.
Take recreational drugs
Has to sit most of the day because of the problem.
Do not take recreational drugs
Is more irritable because of the problem.
Stays in bed most of the day because of the problem.
OCCUPATIONAL HISTORY
Your Employer ___________________________________________
What is your current job satisfaction:
Very Satisfied
Job Title ________________________________________________
Satisfied
Dissatisfied
Are your Job Duties physically demanding for you?
Yes
No
Very Dissatisfied
Have you had any disability time?
Yes
No
If you are currently working, which are you performing?
Your highest level of education attained?
Regular Duties
___________________________________
Limited – Light Duties
MEDICAL HISTORY
List the Physicians and other practitioners your have seen for this problem: List the Medications you are currently taking:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
List the treatments you have had for your problem
List the types of Diagnostic Testing that has been
Hot packs / Ultrasound
Chiropractic
performed for this problem
Massage
Osteopathy
X-rays
Electrical Stimulation
Biofeedback
CT Scan
TENS Unit
Trigger Point Injections
Myelogram
Body Mechanics Training
Epidural Injections
MRI Scan
Strengthening Exercises
Back Brace
Discogram
Aerobics
Acupuncture
Bone Scan
Gravity Inversion – Traction
Naturopathy
EMG
Bed Rest
Release Chiropractic and Wellness Center, 640 East Eisenhower Blvd. Suite 100, Loveland, CO 80537
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