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MEDICAL HISTORY QUESTIONNAIRE
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Name you prefer to be called
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Employment Information
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Patient Employer
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Occupation
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Employer Address
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City:
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State
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Zip
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Work Phone No and Ext
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Patient's Spouse
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Phone
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Family Physician
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Phone
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Who may we thank for referring you to us?
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General Health
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Present Status
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Are you in good health at the present time
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Are you under doctor's care at the present time
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Are you taking medications at the present time
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Constipation history (bowel movement difficulty)
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History of frequent Headaches?
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Migraines?
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Do you smoke?
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History of Heart Attack or Chest Pain?
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Any Allergies to any medications?
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Do you suffer from Allergies
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History of Glaucoma?
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History of High Blood Pressure?
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History of Swelling Feet?
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History of Diabetes?
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History of Sleep Apnea
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Serious Injuries
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Any Surgery? (non-orthopedic)
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Past Medical History
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Comments
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Family Medical History
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Reproductive Health
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Female History
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1. Menopause
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2. Average Cycle Duration (in days)
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3. Are you regular
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4. Pain Associated?
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5. Last Menstrual Period
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6. Birth Control
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7. Last Annual Exam
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Check all that apply
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Male History
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Sexual Function
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Check all that apply
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Past Medical History
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Comments
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Family Medical History
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Nutritional Health
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Nutritional Assessment
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Do you awaken hungry during the night?
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How often do you eat out?
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How often do you eat "fast foods"
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Do you wake up in the morning hungry
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What time of the day are you most hungry?
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What is your activity level?
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On average, hours of sleep do you get per night?
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Allergy Assessment
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Symptoms most commonly associated with allergies
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Less commonly noted symptoms include
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Heavy Metal Toxicity
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Had sore gums (gingivitis) often over the years?
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Mental symptoms such as confusion/forgetfulness?
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Have you had ringing in the ears (tinnitus)?
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Unusual shakiness (tremors) of hands/arms
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Do you have "brown spots" or "age spots"
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Tended to have more cold/flu/other diseases
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Have you had food allergies or intolerance's
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Been to doctors and they said nothing is wrong?
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Numbness or burning sensation in mouth/gums
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Numbness/unexplained tingling in legs/arms?
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Do you have 10 or more "Silver" fillings?
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Do you often have a metallic taste in your mouth
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Worked as a painter/ in mills that used mercury
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Worked as a dentist, hygienist/dental assistant
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Have you ever had any of the following?
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Do you have?
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Frequent low basal body auxiliary temperature
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Do you have problems with constipation?
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Do you have heart irregularities or rapid pulse
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Any unexplained arthritis in various joints?
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Do you have a lot of mucus in your stools?
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Unidentified chest pains even after EKG/X-ray
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Do you have poor sleep or frequent insomnia?
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Frequent kidney infections/kidney problems?
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Fatigued much of the time/never have energy?
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Irritability or dramatic changes in behavior?
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On antidepressants now or have been in the past?
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Orthopedic Health
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Locate the areas of pain- Front
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Pain Level:
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Locate the areas of pain- Back
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Pain Level:
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Date of Injury/onset
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How did you get hurt?
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Has this been a problem before?
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If YES, please explain:
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Continuous (all day):
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Explain Where?
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Intermittent (on & off):
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Explain Where?
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Occasionally:
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Explain Where?
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What makes your pain worse?
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How long can you currently Sit (for ____min)
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How long can you currently Stand (for___min)
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How long can you currently Walk (for___min)
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How long can you currently Run (for___min)
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What makes your pain better?
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Other
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Pain limit your activities of daily living?
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If yes, what percent of the day?
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What can you NOT do or have difficulty doing now
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Self care
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Physical Activity
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Hand Activity
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Travel
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Sexual Function
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Pain keep you from doing the exercises you want?
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If yes, please describe
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Does the pain affect your sleep?
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If yes, please describe your sleeping habits
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What treatments have you had?
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Physical Therapy: Dates Done____
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Did this help?
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Chiropractic Therapy: Dates Done____
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Did this help?
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Acupuncture: Dates Done____
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Did this help?
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Osteopathic Manual: Dates Done____
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Did this help?
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Trigger Point Injections: Dates Done____
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Did this help?
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Joint Injections: Dates Done____
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Did this help?
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Epidural/Facet Injection: Dates Done____
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Did this help?
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Surgeries: Dates Done____
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Did this help?
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Surgeries: Dates Done____
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Did this help?
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Other: Dates Done____
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Did this help?
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Other: Dates Done____
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Did this help?
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Other: Dates Done____
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Did this help?
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