Patient History Form Page 2

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Is this condition worse during certain times of the day?________________________________________________________
Is this condition interfering with
Work?__________ Sleep?__________Routine?_______Other?______________________
Is this condition progressively getting worse?________________________________________________________________
Other Doctors seen for this condition_______________________________________________________________________
Any home remedies? ___________________________________________________________________________________
Please Circle where you are at: (No Complaint/Pain) 0 1 2 3 4 5 6 7 8 9 10 (Worst Possible Complaint/Pain)
Using the symbols below, mark on the pictures where you feel pain.
Numbness
= = =
Dull Ache
OOO
Burning
XXX
Sharp/Stabbing
/ / /
Pins, Needles
+ + +
Other ______
^ ^ ^
Please mark any of the following conditions or symptoms that you have now or have experienced:
Other Symptoms:
O Headaches
O Pain in Hands or Arms
O Chest Pains
O Neck Pain
O Numbness in Hands or Arms
O Heart Attack
O Sleeping Problems
O Pain in Legs or Feet
O High Blood Pressure
O Low Back Pain
O Numbness in Legs or Feet
O Stroke
O Nervousness
O Fatigue
O Cancer
O Tension
O Depression
O Painful Urination
O Irritability
O Lights Bother Eyes
O Diabetes
O Dizziness
O Loss of Memory
O Diarrhea
O Pain Between Shoulders
O Shoulder Pain
O Constipation
O Neck Stiff
O Sinus
O Stomach Upset
O Joint Swelling
O Shortness of Breath
O Heartburn/Reflux
O Fever
O Asthma
O Weight Loss
O Loss of Balance
O Allergies
O Loss of Smell or Taste
O Ringing in Ears
O Cold Hands
O Menstrual Cramps
O Jaw/TMJ Problems
O Cold Feet
O Menopause
Are you under medical care for any condition?_______________________________________________________________________
What Medications are you taking?________________________________________________________________________________
How long?_________________ Have you had surgery?_________________ What?_________________ When?_________________
What side effects have you experienced from the drugs and surgery?_____________________________________________________
Females Only – Date last Menstrual Period began on________________________________ Are you possibly Pregnant?___________
Is there a family History of:
Heart Disease
Arthritis
Cancer
Diabetes Other__________________
Father’s side
O
O
O
O
O
Mother’s side
O
O
O
O
O
I hereby certify that the statements and answers given on this form are accurate to the best of knowledge and understand it is my responsibility
to inform this office of any changes in my health.
I agree to allow this office to examine me for further evaluation.
Patient Signature______________________________________________________Date__________________________

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