Frederick Chiropractic
CONFIDENTIAL PATIENT HEALTH HISTORY
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PATIENT INFORMATION
First AND Last Name:
*
Preferred Name:
Date of Birth:
*
-
Month
-
Day
Year
Date
Billing Address:
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Address
Street Address Line 2
City
State
Zip
Home Phone:
Mobile:
*
Work:
Social Security number:
Height:
Weight:
Email:
*
example@example.com
Gender:
Marital Status:
Married
Single
Other
Occupation:
Employer:
Spouse/Significant Other:
Childrens Names and Ages:
Are you:
Military Veteran
Active Duty Service Member
Reservist
National Guard
ROTC
Referred by:
Family
Friend
CoWorker
Doctor
Other
Referred by (name):
Preferred Language:
Ethnicity
NOT Hispanic or Latino
Hispanic or Latino
Other
Decline to Answer
Race:
Asian
Black or African American
American Indian or Alaskan Native
White (caucasian)
Hawaiian or Pacific Islander
Other
Decline
CMS requires providers to report both race and ethnicity
Smoking Status
Every Day
Some Days
Former
Never
EMERGENCY CONTACT INFORMATION
Full Name:
*
Preferred Contact Number:
*
Relationship:
*
Child
Parent
Spouse
Other
Primary Care Physician:
Primary Care Physician's Phone Number:
Financial Status
Self Pay (Cash)
Insurance
Personal Injury/Auto
Please upload a copy of your insurance cards so that we can look up your benefits PRIOR to your appointment.
If possible, please attach a picture of the FRONT of your insurance card(s)
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If possible, please attach a picture of the BACK of your insurance card(s)
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Primary Insurance Name:
Secondary Insurance Name:
Name of Policy Holder:
Date of Birth of Policy Holder:
Relation to Policy Holder:
Self
Spouse
Parent
Child
Major Complaint: (If you have no complaints and are coming in for wellness, type in "Wellness")
*
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Current Condition Information
Please Answer ALL Questions
When Did It Start (date):
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What Event Caused It:
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Is the Complaint:
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Constant
On and Off
Is the Complaint:
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Sharp
Burning
Dull
Pins and Needles
Stabbing
Achy
Stiff and Sore
Other
Intensity:
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None
Mild
Moderate
Severe
Does it Radiate/Shoot to any areas of your body?
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No
Yes
If YES, where:
Draw Areas of Complaints
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What makes it better?
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Ice
Heat
Rest
Movement
Stretching
Over the counter medication
Prescription medication
Chiropractic
What makes it worse?
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Sit
Stand
Walk
Lying
Sleep
Movement
Who else have you seen for this?
No One
Doctor of Chiropractic
Medical Doctor
Physical Therapist
Masseuse
Emergency Room
Where did you receive this service?:
Diagnostic Tests you have had done for this complaint:
None
X-Rays
MRI
CT Scan
When and Where these tests were completed:
Any Other Complaints?:
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Past History
Does anyone in your IMMEDIATE family have a history of:
Heart Disease: If yes, who
Stroke: If yes, who
Cancer: If yes, who
Other Relevant Family History:
Past Health History (List any Injuries, Traumas, or Hospitalizations in the last 20 years):
Had an auto accident? If so, what year?
Have you ever had a head injury? If so, what year?
List any Surgeries: Date, Type, and Reason
List any medications, vitamins and supplements you are taking: (If you prefer you can bring a list and we will make a copy)
List any Allergies to Medications:
Are you CURRENTLY experiencing any of these symptoms?
Check all that apply
General:
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Recent Intentional Weight Change
Fever
Fatigue
None
Musculoskeletal:
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Low Back Pain
Mid Back Pain
Neck Pain
Arm Problems
Leg Problems
Broken Bones
Muscle Spasms/Cramps
None
Neurological
*
Numbness or Tingling Sensations
Loss of Feeling
Dizziness or Light Headed
Frequent or Recurrent Headaches
Convulsions or Seizures
None
Gastrointestinal
*
Loss of Appetite
Blood in Stool
Change in Bowel Movements
Nausea or Vomiting
Abdominal Pain
Constipation
None
Cardiovascular & Heart
*
Chest Pains
Rapid or Heartbeat CHanges
Blood Pressure Problems
Swelling of Hands, Ankles, or Feet
Heart Problems
None
Respiratory
*
Difficulty Breathing
Persistent Cough
Coughing Blood
Asthma or Wheezing
Tobacco Use
None
Eyes & Vision
*
Wears Contacts/ Glasses
Blurred or Double Vision
Eye Disease or Injury
None
Ears, Nose & Throat
*
Swollen Glands in Neck
Ringing in Ears
Ear Ache/Ringing/ Drainage
Sinus/ Allergy Problems
None
Mind/Stress
*
Nervousness
Depression
Sleep Problems
Memory Loss or Confusion
None
Endocrine, Hematologic & Lymphatic
*
Thyroid Problems
Diabetes
Cold Extremities
Heat or Cold Intolerance
Immune System Disorder
None
Skin & Breasts
*
Rash or Itching
Non- Healing Sores
Breast Pain
Breast Discharge
None
Genitourinary
*
Kidney Stones
Burning/ Painful Urination
Change in Force/Strain with Urination
Urinary Leakage or Bed Wettng
Blood in Urine
None
Is there anything else you would like us to know?
Are you pregnant?
Yes
No
If yes, how many weeks and who is on your birth team?
Women: If you are NOT pregnant, write down date of last menstrual period
Women: Previous Pregnancies Outcome and Date
Women: Check any that apply
Painful or Irregular Periods
Urine Leakage with Coughing or Sneezing
Urine Leakage with Laughing or Lifting
None
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What are your health goals? (Select all that apply)
*
Pain Relief
Sleep Better
Increase Energy
Reduce Stress
Better Posture
Joint Flexibility
Less Sickness
Reduce Need for Medications
Strengthen Immune System
Improve Quality of Life
Overall Wellness
Authorizations and Notice of Privacy Policies
Please sign below to indicate that you have read the above information and have filled out this form as accurately as possible.
Signature
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I have reviewed the HIPAA privacy practices for Frederick Chiropractic (above).
Parent or Guardian Signature
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Date
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All Set! Select "Submit" below, and we will receive your information. We look forward to meeting you.
-Frederick Chiropractic Team
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