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  • Patient History Form

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    Agile9204
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    Patient information contained within this form is considered strictly confidential. Each item should be utilized as a diagnostic option based on the patient's presenting symptoms and the clinical discretion of the examiner.

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    Patient information contained within this form is considered strictly confidential. Each item should be utilized as a diagnostic option based on the patient's presenting symptoms and the clinical discretion of the examiner.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    20 views1 page

    Patient History Form

    Uploaded by

    Agile9204
    Patient information contained within this form is considered strictly confidential. Each item should be utilized as a diagnostic option based on the patient's presenting symptoms and the clinical discretion of the examiner.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    Patient History

    Name:_________________________________ date: ______ Insurance #: _______________________________ (dd/mm/yr) DOB: _____________________________________ M / F

    Review intake questionnaire Presenting complaint 1. Location/radiation 2. Onset (when/how) 3. Chronology/timing/prior episodes 4. Quality (sharp, dull, shooting) 5. Severity (0-10)/effect on ADL 6. Modifying factors (better/worse) 7. Associated symptoms (NTW) 8. Treatment history/relevant prior injuries/X-rays 9. Why seeking care now 10. Treatment goals

    Past health history 1. Serious illness 2. Hospitalizations/surgeries (including residual problems) 3. General trauma, accidents, injuries (including residual problems) 4. Menses, menopause 5. Contraceptives, pregnancies 6. Medications: prescription/OTC (purpose, dose, frequency) 7. Allergies 8. X-rays/imaging 9. Prior care (chiro, naturo, medical, massage, PT) 10. Last physical (date/results)

    Family health history 1. Hereditary disease/family health problems

    Personal/social history 1. Living situation 2. Occupation (activities/hours) 3. Exercise (activities/frequency) 4. Interests / other activities 5. Diet (good, fair, poor) 6. Sleep pattern (wake rested) 7. Bowel habits (freq., changes) 8. Urinary habits (changes, prob.) 9. Habits (alcohol, tobacco, drugs) 10. Stress factors Is there anything else?
    Patient information contained within this form is considered strictly condential. This form is a comprehensive checklist of standard patient history questions. Each item should be utilized as a diagnostic option based on the patients presenting symptoms and the clinical discretion of the examiner. Reproduction is permitted for personal use, not for resale. www.prohealthsys.com 2005 by Professional Health Systems Inc. Dedicated to Clinical Excellence.

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