Health History Questionnaire Outline of Procedure for New Patients 1. STEP ONE: All new patients are requested to fill out a personal health history questionnaire. 2. STEP TWO: Consultation with the doctor to discuss your health problems. 3. STEP THREE: According to the information derived from the consultation, the doctor will order appropriate exams or x-rays specific to your condition. Exams may include orthopedic, neurological, palpation, reflex analysis, iris analysis, or range of motion exams. The doctor may also inform you that your condition may require another type of health specialist. 4. STEP FOUR: The doctor will review with you the diagnostic examinations, explain their significance, and make recommendations for treatment. Family members are welcome to accompany you. 5. STEP FIVE: Treatments will begin and continue as scheduled until your condition has been fully corrected or until the maximum possible improvement has been obtained. Your condition may require periodic treatment or monitoring in order to maintain high level wellness. If you do not respond to treatment, or are dissatisfied with your progress, you may stop taking treatment at any time without further financial obligation, except for services previously rendered. In addition, upon request your case records will be made available for review by the physician of your choice. 6. STEP SIX: Financial Arrangements. If you have insurance, you'll be happy to know Medicare,Worker's Compensation, Automobile Med-Pay, and many union and company health insurance policies provide chiropractic coverage. See separate financial policy form that further explains the specifics of your case along with the information we derive upon calling your insurance carrier to confirm coverage. E:\DOCS\FORMS\NEWPTNT5.DOC
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Health History Questionnaire
Outline of Procedure for New Patients
1. STEP ONE: All new patients are requested to fill out a personal health history questionnaire.
2. STEP TWO: Consultation with the doctor to discuss your health problems.
3. STEP THREE: According to the information derived from the consultation, the doctor will order appropriate exams or x-rays specific to your condition. Exams may include orthopedic, neurological, palpation, reflex analysis, iris analysis, or range of motion exams. The doctor may also inform you that your condition may require another type of health specialist.
4. STEP FOUR: The doctor will review with you the diagnostic examinations, explain their significance, and make recommendations for treatment. Family members are welcome to accompany you.
5. STEP FIVE: Treatments will begin and continue as scheduled until your condition has been fully corrected or until the maximum possible improvement has been obtained. Your condition may require periodic treatment or monitoring in order to maintain high level wellness. If you do not respond to treatment, or are dissatisfied with your progress, you may stop taking treatment at any time without further financial obligation, except for services previously rendered. In addition, upon request your case records will be made available for review by the physician of your choice.
6. STEP SIX: Financial Arrangements. If you have insurance, you'll be happy to know Medicare,Worker's Compensation, Automobile Med-Pay, and many union and company health insurance policies provide chiropractic coverage. See separate financial policy form that further explains the specifics of your case along with the information we derive upon calling your insurance carrier to confirm coverage.
Sinus Infection Painful Hip Do you think you might be Pregnant?
Sore Throat Painful Knee ( ) Yes ( ) No
Tonsillitis Painful Shoulder
Painful Tail Bone
Painful Wrist
Spinal Curvature/Scoliosis
Stiff Neck
Swollen Joints
Patient's Signature
SYMPTOM SURVEY FORM(Restricted to Professional Use)
PATIENT AGE- DOCTOR DATE-INSTRUCTIONS: Circle the number that applies to you. lf a symptom does not apply, leave it blank.
Circle either: (1) for MILD symptoms (occurs rarely), (2) for MODERATE symptoms (occurs several times a month),or (3) for SEVERE symptoms (occurs almost constantly).
GROUP THREE42-123 Eatwhennervous 49-123 Heartpalpitatesif meals 53-123 Cravecandyorcoffee43 - 1 2 3 Excessive appetite missed or delayed in afternoons44-12 3 Hungrybetweenmeals 50- 12 3 Afternoonheadaches 54- 12 3 Moodsof depression-45- 12 3 lrritablebeforemeals 51 - 12 3 Overeatingsweetsupsets "blues"ormelancholy46 - 1 2 3 Get"shaky"if hungry 52- 12 3 Awakenafterfewhourssleep 55 - 12 3 Abnormal cravingfor47 - 1 2 3 Fatigue, eating relieves - hard to get back to sleep sweets or snacks48 - 1 2 3 "Lightheaded"if mealsdelayed
Hands and feet go to sleepeasily, numbnessSigh frequenlly, "airhunger"Aware of "breathingheavily"High altitude discomfortOpens windows inclosed roomSusceptible to coldsand feversAfternoon "yawner"
GROUP FOUR63 - 1 2 3 Get"drowsy"often64-123 Swollenankles
worse at night65 - 1 2 3 Musclecramps,worse
during exercise; get"charley horses"
66 - 1 2 3 Shortnessof breathon exertion
67 - 1 2 3 Dull pain in chest orradiating into left arm,worse on exertion
painful or difficult- 1 2 3 Worrier, feels insecure
GROUP FIVE83 - 1 2 3 Feeling queasy; headache
90-123
over eyesGreasy foods upsetStools light-coloredSkin peels on foot solesPain between shoulderbladesUse laxativesStools alternate fromsoft to wateryHistory of gallbladderattacks or gallstones
GROUP SIX- 12 3 Coatedtongue- 1 2 3 Pass large amounts of
foul-smelling gas
Sneezing attacksDreaming, nightmare typebad dreamsBad breath (halitosis)Milk products causedistressSensitive to hot weatherBurning or itching anusCrave sweets
98 - 1 2 3 Loss of taste for meat 10199 - 1 2 3 Lower bowel gas several 102
GROUP EIGHTApprehensionlrritabilityMorbid fearsNever seems to get wellForgetfulnesslndigestionPoor appetiteCraving for sweetsMuscular sorenessDepression; feelings of dreadNoise sensitivityAcoustic hallucinationsTendency to crywithout reasonHair is coarse and/orthinningWeaknessFatigueSkin sensitive to touchTendency toward hivesNervousnessHeadachelnsomniaAnxietyAnorexialnability to concentrate;confusionFrequent stuffy nose; sinusinfectionsAllergy to some foodsLoose joints
IMPORTANTTO THE PATIENT: Please list below the five main physical complaints you have in order oftheir importance.
1.
2.
3.
4
5
Postural Blood Pressure: Recumbent
Hema-Combistix Urine readings: pH
Occult Blood pH of Saliva
Hemoglobin Blood Clotting Time
(TO BE COMPLETED BY DOCTOR)
Standing
Albumin per cent_ Glucose per cent
pH of Stool specimen Weight
BARNES THYROID TESTThis test was developed by Dr. Broda Barnes, M.D. and is a measurement of the underarm tem-perature to determine hypo and hyperthyroid states. The test is conducted by the patient in thea.m. belore leaving bed - with the temperature being taken lor 10 minutes. The test is invalidatedil the patient expends any energy prior to taking the test - getting up lor any reason, shaking down
You can do the lollowing test at home to see i, you may have a lunctional low thyroid.Use an oral thermometer or a digital one- When you use a digital one, place the probeunder your arm for 5 minutes then turn your machine on; continue on for an addition-al 5 minutes. When using a regular one, shake down the night before.
the thermometer, etc. lt is important that the test be conducted ,or exactly l0 minutes, making theprior positioning of both the thermometer and a clock important.
PRE-MENSES FEMALES AND MENOPAUSAL FEMALESAny two days during the month
FEMALES HAVING MENSTRUAL CYCLESThe 2"d and 3" day of flow OR any 5 days in a row.