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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