Parkhurst Chiropractic & Lakeshore Wellness Center New Patient Health History Form In order to provide you the best possible wellness care, please complete this form and bring it to your first appointment. All information is strictly CONFIDENTIAL. Patient Data Name ___________________________________ Date ________ Email _______________________________________ Your email will NOT be shared with any 3d parties, and is used for occasional office announcements and promotions. Address ________________________________________ City _______________ State ________________ Zip _______ Telephone – Please check preferred method of contact (work) _____________________ (home) ______________________________(cell)_________________________ Age _________Birth date _____________________Marital Status _________________ Occupation ______________________Employer________________________________________________ Emergency contact __________________________________Phone ____________________________ Demographics* *Information required by Affordable Care Act Height:__________ Weight:______________ Tobacco Use?  No  Yes  Former High Blood Pressure?  No  Yes _________________________ Alcohol Use?  Never  Occasionally  Socially  Frequently (more than 3 days per week) Patient Race:  Asian  Black/African American  Caucasian/White  Latin American  Native American  Pacific Islander  Other _____________________________________ Language:__________________________________________________ List your top 3 Current Complaints Check all that apply 1._____________________________________________________ _______________________________________________________ 2._____________________________________________________ _______________________________________________________ 3._____________________________________________________ _______________________________________________________ Headaches Neck Pain Upper Back Pain Lower Back Pain Hip Arm Leg Yes        How did your symptoms begin?  Automobile  Work  Accident  Trauma  Illness  Aggravation of Congenital Problem, Onset started as follows: ___________________________________________________________________________ What best describes your symptoms? (check all that apply)  throbbing  shooting  torturing  sharp  burning  numbing  nagging  cramping  constant  dull  aching  intermittent  radiating  hypersensitive Comments________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ What worsens your pain or symptoms? (check all that apply)  standing  bending  emotional stress  sleeping  walking  sexual activity  menstruating  sitting  touching affected area  moving from a sitting to standing position  Other ___________________________________________________________________________________________ Has your problem decreased or prevented your ability to exercise:  Yes  No Parkhurst Chiropractic & Lakeshore Wellness Center Medical History Primary Care Physician _____________________________________________________________________ Date of last physical exam ____________________________ Is there a chance that you are pregnant?  No  Yes What Prescription Medications or Supplements are you taking (Please list dosage and amounts, etc). __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ What drug allergies are you aware of? ___________________________________________________________________________________________________________ Check all past and present medical health problems (please select all that apply) I am in Good Health Diabetes Lung Disease Stomach problems Ulcer Disease Kidney Disease Mitral Valve Prolapse High Cholesterol Heart Problems Liver Problems Asthma Bleed Easily Arthritis Indicate all past surgeries No History of Surgical Procedures Please list all past surgeries Yes Briefly Explain              Yes Briefly Explain     Family History – Indicate if your parents, sisters or brothers had any of these conditions. No family history of problems Arthritis High Blood Pressure High Cholesterol Diabetes Heart Disease Cancer Chronic Pain Yes           Briefly Explain Parkhurst Chiropractic & Lakeshore Wellness Center Review of Systems If you have an issue in a section below, check your issue. If you have no problems relating to that question, check the “No Problems” box. Do any of the following apply? No Problems Fatigue Night Sweats Weight Issues Loss of Energy Do you have any endocrine problems? No Problems Diabetes Thyroid Disorder Yes       Yes    Do any of the following apply? No Problems Irritability Depression Disturbed Sleep Anxiety Nervousness Do you have any neurological problems No Problems Seizures Loss of Memory Yes       Yes    Do you have any of the issues below? If yes, please explain. Do you have any trouble urinating?  No  Yes If yes, explain _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ Do you have trouble with your vision?  No  Yes If yes, explain __________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ Do you have any symptoms of heart trouble?  No  Yes If yes, explain __________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ Do you have any breathing problems?  No  Yes If yes, explain ________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ Do you have any stomach problems?  No  Yes If yes, explain __________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ Do you have muscle or joint pain?  No  Yes If yes, explain ____________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ Do you have any allergy/immunity problems?  No  Yes If yes, explain __________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ Do you have bruising or bleeding problems?  No  Yes If yes, explain ___________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________