"Arctic Chiropractic Patient Intake Form"

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Name:
Arctic Chiropractic
____________________________________
_________
Date:
Patient Intake Form
Insurance: _______________________________________
(mm/dd/yr)
□ male □ female
Patient information contained within this form is
Date of Birth: __________________________________
considered strictly confidential.
Address: ______________________________________
Marital status
Your responses are important to help us better
______________________________________
understand the health issues you face and ensure
How did you hear about us? _____________________
S
M W
D SEP
the delivery of the best possible treatment.
Phone #: home: _________________ work: ____________________
E-mail address: ___________________________________________
Occupation: _________________ Employer: ___________________
Check  and indicate the age when you had any of the following:
General
Gastrointestinal
Cardiovascular
Check any of the conditions
you have or have had:
Allergies
Abdominal pain
High blood pressure
Alcoholism
Depression
Bloody or tarry stool
Low blood pressure
Anemia
Dizziness
Colitis / Crohn’s
Hardening of the arteries
Appendicitis
Fainting
Colon trouble
Irregular pulse
Arteriosclerosis
Fatigue
Constipation
Pain over heart
Asthma
Fever
Diarrhea
Palpitation
Bronchitis
Headaches
Difficult digestion
Poor circulation
Cancer
Loss of sleep
Diverticulosis
Rapid heart beat
Chicken pox
Mental illness
Bloated abdomen
Slow heart beat
Cold sores
Nervousness
Excessive hunger
Swelling of ankles
Diabetes
Tremors
Gallbladder trouble
Eczema
Weight loss / gain
Hernia
Respiratory
Edema
Hemorrhoids
Chest pain
Emphysema
Muscle / Joint
Intestinal worms
Chronic cough
Epilepsy
Arthritis / rheumatism
Jaundice
Difficulty breathing
Goiter
Bursitis
Liver trouble
Hay fever
Gout
Foot trouble
Nausea
Shortness of breath
Heart burn
Muscle weakness
Painful deification
Spitting up phlegm / blood
Heart disease
Low back pain
Pain over stomach
Wheezing
Hepatitis
Neck pain
Poor appetite
Herpes
Mid back pain
Vomiting
Women only
High cholesterol
Joint pain
Vomiting of blood
Congested breasts
HIV/AIDS
Hot flashes
Skin
Influenza
Genitourinary
Lumps in breast
Boils
Malaria
Bed-wetting
Menopause
Bruise easily
Measles
Bladder infection
Vaginal discharge
Dryness
Miscarriage
Blood in urine
Menstrual flow
Hives or allergies
Multiple sclerosis
Kidney infection
Reg.
Irreg.
Pain / cramps
Itching
Mumps
Kidney stones
Days of flow: ____ Length of cycle: _____
Rash
Numbness/tingling
Prostate trouble
Date - 1
day last period: ______________
st
Varicose veins
Pace maker
Pus in urine
Are you pregnant?
yes,
no
Osteoporosis
Stress incontinence
If yes, how many months? _____
Eye, Ear, Nose & Throat
Pneumonia
Urination
How many children do you have? _____
Colds
Polio
Overnight more than twice
Birth control method: ________________
Deafness
Rheumatic fever
More than 8x in 24hrs
Date of last PAP test: ________________
Ear ache
Stroke
Decreased flow/force
normal,
abnormal
Eye pain
Thyroid disease
Painful urination
Date of last mammogram: ______________
Gum trouble
Tuberculosis
Urgency to urinate
normal,
abnormal
Hoarseness
Ulcers
Nasal obstruction
Nose bleeds
Please list any medication you are currently taking and why:
Ringing of the ears
__________________________________________________________________________________________
Sinus infection
__________________________________________________________________________________________
Sore throat
_____________________________________________________________________________________________________________
Tonsillitis
_____________________________________________________________________________________________________________
Vision problems
Reproduction is permitted for personal use, not for resale or redistribution. www.prohealthsys.com ©2012 by Professional Health Systems Inc. “Dedicated to Clinical Excellence.”
Name:
Arctic Chiropractic
____________________________________
_________
Date:
Patient Intake Form
Insurance: _______________________________________
(mm/dd/yr)
□ male □ female
Patient information contained within this form is
Date of Birth: __________________________________
considered strictly confidential.
Address: ______________________________________
Marital status
Your responses are important to help us better
______________________________________
understand the health issues you face and ensure
How did you hear about us? _____________________
S
M W
D SEP
the delivery of the best possible treatment.
Phone #: home: _________________ work: ____________________
E-mail address: ___________________________________________
Occupation: _________________ Employer: ___________________
Check  and indicate the age when you had any of the following:
General
Gastrointestinal
Cardiovascular
Check any of the conditions
you have or have had:
Allergies
Abdominal pain
High blood pressure
Alcoholism
Depression
Bloody or tarry stool
Low blood pressure
Anemia
Dizziness
Colitis / Crohn’s
Hardening of the arteries
Appendicitis
Fainting
Colon trouble
Irregular pulse
Arteriosclerosis
Fatigue
Constipation
Pain over heart
Asthma
Fever
Diarrhea
Palpitation
Bronchitis
Headaches
Difficult digestion
Poor circulation
Cancer
Loss of sleep
Diverticulosis
Rapid heart beat
Chicken pox
Mental illness
Bloated abdomen
Slow heart beat
Cold sores
Nervousness
Excessive hunger
Swelling of ankles
Diabetes
Tremors
Gallbladder trouble
Eczema
Weight loss / gain
Hernia
Respiratory
Edema
Hemorrhoids
Chest pain
Emphysema
Muscle / Joint
Intestinal worms
Chronic cough
Epilepsy
Arthritis / rheumatism
Jaundice
Difficulty breathing
Goiter
Bursitis
Liver trouble
Hay fever
Gout
Foot trouble
Nausea
Shortness of breath
Heart burn
Muscle weakness
Painful deification
Spitting up phlegm / blood
Heart disease
Low back pain
Pain over stomach
Wheezing
Hepatitis
Neck pain
Poor appetite
Herpes
Mid back pain
Vomiting
Women only
High cholesterol
Joint pain
Vomiting of blood
Congested breasts
HIV/AIDS
Hot flashes
Skin
Influenza
Genitourinary
Lumps in breast
Boils
Malaria
Bed-wetting
Menopause
Bruise easily
Measles
Bladder infection
Vaginal discharge
Dryness
Miscarriage
Blood in urine
Menstrual flow
Hives or allergies
Multiple sclerosis
Kidney infection
Reg.
Irreg.
Pain / cramps
Itching
Mumps
Kidney stones
Days of flow: ____ Length of cycle: _____
Rash
Numbness/tingling
Prostate trouble
Date - 1
day last period: ______________
st
Varicose veins
Pace maker
Pus in urine
Are you pregnant?
yes,
no
Osteoporosis
Stress incontinence
If yes, how many months? _____
Eye, Ear, Nose & Throat
Pneumonia
Urination
How many children do you have? _____
Colds
Polio
Overnight more than twice
Birth control method: ________________
Deafness
Rheumatic fever
More than 8x in 24hrs
Date of last PAP test: ________________
Ear ache
Stroke
Decreased flow/force
normal,
abnormal
Eye pain
Thyroid disease
Painful urination
Date of last mammogram: ______________
Gum trouble
Tuberculosis
Urgency to urinate
normal,
abnormal
Hoarseness
Ulcers
Nasal obstruction
Nose bleeds
Please list any medication you are currently taking and why:
Ringing of the ears
__________________________________________________________________________________________
Sinus infection
__________________________________________________________________________________________
Sore throat
_____________________________________________________________________________________________________________
Tonsillitis
_____________________________________________________________________________________________________________
Vision problems
Reproduction is permitted for personal use, not for resale or redistribution. www.prohealthsys.com ©2012 by Professional Health Systems Inc. “Dedicated to Clinical Excellence.”
Patient Intake Form
(side 2)
Give a brief detailed description of the problem you are currently experiencing: _____________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
________________________________________
How long have you had this condition? _____________
Is it getting worse? □ yes, □ no ___________________________________
Does it bother you (check appropriate box): □ work, □ sleep, □ other: ___________________________________________________
What seemed to be the initial cause: _______________________________________________________________________________
Please mark you area(s) of pain on the figure below
Please place a mark at the level of
your pain on the scale below:
Worst
Possible
Pain
No
Pain
Past health history
Habits
none light mod. heavy
Alcohol
Have you...
Yes No If yes, explain briefly
Coffee
... been hospitalized in the last 5 year?
□ □ ____________________________________
Tobacco
... had any mental disorders?
□ □ ____________________________________
Drugs
... had any broken bones?
□ □ ____________________________________
Exercise
... had any strains or sprains?
□ □ ____________________________________
Sleep
... ever used orthotics?
□ □ ____________________________________
Soft drinks □
Do you take minerals, herbs or vitamins?
□ □ ____________________________________
Salty foods □
How is most of your day spent? □ standing, □ sitting, □ other: _________________________
Water
How old is your mattress? ___________________
Sugar
When was your last physical exam? ______________________
Family history
If any blood relative has had any of the following conditions, please check and indicate which relative(s)
□ Alcoholism
□ Cancer
□ High blood pressure
□ Anemia
□ Diabetes
□ High cholesterol
□ Arteriosclerosis
□ Emphysema
□ Multiple sclerosis
□ Arthritis
□ Epilepsy
□ Osteoporosis
□ Asthma
□ Glaucoma
□ Stroke
□ Bleed easily
□ Heart disease
□ Thyroid disease
Do you have any other health issues or concerns that our staff should be made aware of? _______________________________
____________________________________________________________________________________________________________
Reproduction is permitted for personal use, not for resale or redistribution. www.prohealthsys.com ©2012 by Professional Health Systems Inc. “Dedicated to Clinical Excellence.”
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