Confidential Patient Data

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PATIENT INFORMATION

Today's Date: June 30, 2004

Name: Male Female

Mailing Address: City: State: Zip:

Home Phone: Work Phone: EXT:

Social Security #: Age: Date of Birth:

Marital Status: Married Single Divorced Separated Other

Name of Spouse or Nearest Relative: Phone:

Reffered to this Office By:
Friend/Family Member - Name? Yellow Pages Mail Clinic Location Web Site Other

Your Occupation: Your Employer:

Payment for services will be by:
Cash Check Credit Card Health Insurance Automobile Insurance Worker's Compensation

Name of Insurance Co.: Group #: Phone:

Insured's ID #: Insured's Date of Birth:

Are you covered by more than one insurance company? No Yes-Name

MEDICAL/FAMILY HISTORY

S=SELF M=MOTHER F=FATHER

(Please indicate wich conditions have been experienced by the above by marking appropriate boxes).

S	M	F		S	M	F		S	M	F
			AIDS				dislocated joints				neck pain
			anemia				epilepsy				nervousness
			arthritis				German Measles				numbness
			asthma				headaches				polio
			back pain				heart trouble				poor circulation
			bladder trouble				reproductive disorders				hepatitis
			bone fracture				high blood pressure				rheumatic fever
			cancer				HIV/ARC				rheumatism
			chest pain				kidney disorder				scarlet fever
			concussion				bowel control loss				serious injury
			convulsions				menstrual cramps				sinus trouble
			diabetes				multiple sclerosis				tuberculosis
			indigestion				muscular dystrophy				other

Have you been treated by a physician for any health condition in the past year? Yes No
Describe condition: Date of Last Physical Exam:

SURGICAL HISTORY:
1. Date:
2. Date:
3. Date:

Have you ever had a metal implant? Yes No

Have you ever been gunshot? Yes No

ACCIDENT HISTORY:
Explanation: Date: Job Auto Other
Explanation: Date: Job Auto Other
Explanation: Date: Job Auto Other

PLEASE DESCRIBE PRESENT MAJOR COMPLAINTS

Please Rate Your Symptoms (1-10 with 1 being least serious)

1. Rating

2. Rating

3. Rating

Symptoms are worse in the Morning Afternoon Night

When and how occured?

Symptoms developed from: Job Related Injury Auto Accident Accident Other
Illness Unknown Cause Gradual Onset - Date Occured

Symptoms have persisted for # Hour(s) Day(s) Week(s) Month(s) Year(s)

Symptoms/Complaints: Come & Go Are Constant

Have your ever had this before: No Yes - When?

If you were to guess, what do you think is causing your complaints?

Name and location of doctors previously seen for present condition(s):

Are you allergic to any medications: No Yes - What Kind?

Are you taking any medications: No Yes - What Kind?

Are you pregnant: No Yes - Date of last menstrual period:

Please check the following activities the aggravate your condition:
Bending Reaching Straining at Stool Coughing Sitting Turning Head
Lifting Sneezing Walking Lying Down Standing

Please check the following activities that relieve your condition:
Bending Sitting Lifting Standing Lying Down Turning Head Reaching Walking

Please check any additional symptoms you may be experiencing:
blurred vision	buzzing in ears	cold feet
cold hands	cold sweats	concentration loss/confusion
constipation	depression/weeping spells	diarrhea
dizziness	face flushed	fainting
fatigue	fever	head seems too heavy
headaches	insomnia	light bothers eyes
loss of balance	loss of smell	loss of taste
low resistance to colds	muscle jerking	numbness in fingers
numbness in toes	pins and needles in arms	pins and needles in legs
ringing in ears	shortness of breath	stiff neck
stomach upset

How often are your symptoms present?