Recommended
More Related Content
What's hot
What's hot (20)
Similar to Patient history of illness
Similar to Patient history of illness (20)
More from spinalworks3
Recently uploaded
Recently uploaded (20)
Patient history of illness
- 1. History of illness / injury / pain Primary Complaint - Chief complaint and its location? ______________________________________________________ ________________________________________________________________________________ _________ - What caused the onset? _____________________________________________________________ - What makes it better? _______________________________________________________ - What makes it worse? _______________________________________________________ - When did the pain first start? _____________________________________________your pain Please mark - Describe the pain i.e. (achy, burning, sharp, dull, stabbing, throbbing, numbness) _____________________ - Does the pain radiate? Yes ________ No _________ Where? ______________________________________ - On a scale of 1 – 10 what would you rate your pain? (Circle) 1 2 3 4 5 6 7 8 9 10 - How much of your day do you feel the pain (24 hours)? Quarter day Half day All day _______________ - What time of day do you feel it the most? ______________________________________________________ - Have you lost work days because of it? Yes________ No ________ How many? ______________________ - Was it caused by: Auto Accident __________ Work Related ________ other _________________ - Have you experienced this pain in the past? Yes _______ No ________ How long ago? ________________ - Have you been treated by a chiropractor for this or any other condition? Yes___________ No ___________ If yes, by whom? _____________________________________ How long ago? ________________________ - Were you helped? Yes _________ No ______ Did you follow the Dr’s recommendations? Yes ___ No ____ - Are you currently being treated by another doctor? Yes __ No __ If yes, by whom? ____________________ Why were you being seen? __________________________________________________________________ - Are you currently taking any over the counter or prescription medication? Yes ________ No ___________ If yes, What: ________________________________ For What? _____________________________________ Secondary Complaints. Describe 1. _________________
- 2. _________________________________________________________________ 2. _________________ _________________________________________________________________ 3. _________________ _________________________________________________________________ 4. _________________ _________________________________________________________________ Pain Level for Secondary Complaints Circle How much of your day do you feel it 1. ____________________ 1 2 3 4 5 6 7 8 9 10 Quarter day Half day All day 2. ____________________ 1 2 3 4 5 6 7 8 9 10 Quarter day Half day All day 3. ____________________ 1 2 3 4 5 6 7 8 9 10 Quarter day Half day All day 4. ____________________ 1 2 3 4 5 6 7 8 9 10 Quarter day Half day All day - How do you want us to handle your condition? __________ Maximum Correction (Correct the cause of the problem, so it doesn’t return) __________ Temporary Relief (Pain relief for symptom, no correction) - How did you hear about our office? ___________________________________________________________ Page 1 of 2