kccak- Existing Patient

UPDATED PATIENT HISTORY
Date:

Month Day Year
First Name Middle Name Last Name
I have new contact information
Please select one of the following:

Progress evaluation – I’ve been actively treating, and this is a periodic reevaluation. New condition – I’ve been actively treating and a new or returning condition has developed. Returning patient – I have not been seen in some time and a new or returning condition has developed.
Current Symptoms:
1. Location Circle the area(s) on the illustration where it hurts.
2. Type of symptoms What kind of pain does it feel like?

Numbness Aching Burning Tingling Cramps Shooting Stiffness Nagging Throbbing Dull Sharp Stabbing Other
3. Intensity (Rate your pain when it is at its worst)

1 2 3 4 5 6 7 8 9 10

Absent

Uncomfortable

Agonizing

4. Duration and Timing (In conjunction to the pain you rated in question 3: When did it start and how often do you feel it?)

Constant Comes and goes
When did it start?
5. Radiation (Does it affect other areas of your body? To what areas does the pain radiate, shoot or travel?
6. Aggravating or relieving factors (What makes it better or worse, such as time of day, movements, certain activities, etc.)
Worsens pain:
Lessens pain:
7. Prior interventions (What have you done to relieve the symptoms?)

Prescription Medication Surgery Over-the-counter Drugs Acupuncture Homeopathic Remedies Chiropractic Physical Therapy Massage Ice Heat
8. What else should Dr. Kanady know about your current condition?

9. Review of systems (Identify any changes since your most recent evaluation with us)

	Worse	No change	Improved
a. Musculoskeletal System – Such as osteoporosis, arthritis, neck pain, back problems, poor posture, etc.
b. Neurological System - Such as anxiety, depression, headache, dizziness, pins and needles, numbness, etc.
c. Cardiovascular System – Such as high blood pressure, low blood pressure, high cholesterol, angina, etc
d. Respiratory System – Such as asthma, apnea, emphysema, hay fever, shortness of breath, pneumonia, etc.
e. Digestive System – Such as anorexia/bulimia, ulcer, food sensitivities, heartburn, constipation, diarrhea, etc.
f. Sensory System – Such as blurred vision, ringing in ears, hearing loss, chronic ear infection, etc.
g. Skin System – Such as skin cancer, psoriasis, eczema, acne, hair loss, rash, etc.
h. Endocrine System – Such as thyroid issues, immune disorders, hypoglycemia, frequent infection, etc.
i. Genitourinary System – Such as kidney stones, infertility, bedwetting, prostate issues, PMS symptoms, etc.
j. Constitutional System – Such as fainting, low libido, poor appetite, fatigue, sudden weight, weakness, etc.

10. Illnesses, operations, injuries or treatments since your most recent evaluation with us:
11. Medications (please list all prescription and over-the-counter)

12. Social History (Tell Dr. Kanady about your health habits)

Hobbies:
To the best of my ability, the information I have provided is complete and truthful. I have not misrepresented the presence, severity or cause of my health concern.
If the patient is a minor child, print child’s full name:
Signature

Clear
Date

Month Day Year
Should be Empty: