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

PERSONAL HISTORY

Date: Social Security #:

Name: Street Address:

City: __________________ State: _____ Zip:________E-mail:________________(i.e. suesmith@aol.com)

Home Phone: Business Phone:

Birth Date: Sex: Height: Weight:

Your Employer: Type of Work:

Name & Phone # of Person to Contact in Case of Emergency:

Circle If You Are: Married Single Widowed Divorced Separated

Name of Spouse: SSN: Birth Date:

Parent/Guardian of Patient (if under age 18)_____________________________________________

Spouse's Employer: Phone #:

Person Responsible for Your Bill: ( ) Self ( ) Spouse ( ) Employer ( ) Insurance

( ) Other - name: social security #:________________ birthdate:________

Type of Insurance Coverage: ( ) Workman's Compensation ( ) Auto. Insurance Policy ( ) Medicaid ( ) 3rd Party Auto. Insurance ( ) Medicare ( ) Group Policy ( ) Personal Policy ( ) PPO/HMO

Name of Insurance Company:

Referred to This Office by:

FAMILY HEALTH HISTORY

RELATION NAME AGE PRESENT SYMPTOMS PREVIOUS SERIOUS ILLNESSES

Father

Mother

Siblings

Children

PAST HEALTH HISTORY

PLEASE CHECK APPLICABLE ITEMS – (indicate date of surgery).

OPERATIONS: Appendectomy Cardiovascular/Heart Female Organs

Gall Bladder Hernia Rectal

Spinal Tonsillectomy Others

ACCIDENTS OR FALLS: (Please describe)

FRACTURES OR DISLOCATIONS:

HABITS: Exercise (what type/how often?) Hobbies Sleep (hours)_

Tobacco (How much?) _______________________ Alcohol____drinks per ( )day ( )week ( )month

Coffee (avg. # of cups/day) regular____ decaf.____ Tea (avg. # of cups/day) regular____ herbal___

Soft Drinks (avg. # of 12 oz. cans per day) ( )regular____ ( )diet____ ( )caf. free_____

Water (8 oz. glasses/day) _____ city____ well____ distilled____ spring____ filtered____

List the names and dosages of any drugs you are taking (prescription or non-prescription):

Anti-Inflammatory Medicine Laxatives

Muscle Relaxers Pain Relievers

Other

Vitamins, minerals, herbs, homeopathic remedies______________________________________

_____________________________________________________________________________

Have you been treated for a mental disorder or nervous breakdown?

CIRCLE Any of the Following Diseases You Have Had:

ADD / ADHD Crohn’s Disease Herpes Pleurisy

Alcoholism Diabetes Hodgkin’s Disease Pneumonia

Alzheimer’s Eczema Impotency Raynaud’s Syndrome

Anemia Emphysema Infertility Stroke

Anorexia Endometriosis Multiple Sclerosis Thyroid Condition

Appendicitis Epilepsy Muscular Dystrophy Tourette’s Syndrome

Arthritis Fibromyalgia Osteoporosis Trigeminal Neuralgia

Bell’s Palsy Glaucoma Parkinson’s Disease Tuberculosis

Cancer Goiter Padgett’s Ulcers

Candida Heart Disease Parasites Venereal Infection

Chronic Fatigue Hepatitis Phlebitis Other _________________

Underline All of the Symptoms You Have Had Previously

Circle All of the Symptoms You Have Now

GENERAL SYMPTOMS SKIN GASTROINTESTINAL

Chills Acne Belching or Gas

Convulsions Boils Colitis

Dizziness Bruise Easily Colon Trouble

Fainting Cysts Constipation

Fatigue Dryness Diarrhea

Fever Hives Difficult Digestion

Hair Loss Itching Distention of Abdomen

Headache Sensitive Skin Excessive Hunger

Hernia Skin Eruptions Gall Bladder Trouble

Loss of Sleep Varicose Veins Hemorrhoids

Nervousness Intestinal Worms

Neuralgia / Nerve Pain RESPIRATORY Jaundice

Numbness in arms, hands, or legs Chest Pain Liver Trouble

Pain in arms, hands, or legs Chronic Cough Nausea

Sweats Difficult Breathing Painful Bowel Movements

Tremors Spitting Up Blood Pain Over Stomach

Weak Fingernails Spitting Up Phlegm Poor Appetite

Weight Gain Wheezing Vomiting

Weight Loss Vomiting of Blood

CARDIO-VASCULAR

E.E.N.T. Cold Hands or Feet GENITOURINARY

Allergies Hardening of Arteries Bed Wetting

Asthma High Blood Pressure Frequent Urination

Cataracts High Cholesterol Frequent Kidney or Bladder Infections

Deafness Low Blood Pressure Inability to Control Urine

Dental Decay/Painful Teeth Pain Over Heart Kidney Stones

Ear Discharge Paralytic Stroke Painful Urination

Ear Noises/Ringing Poor Circulation Prostate Trouble

Earache Rapid Beating Heart Pus/Blood in Urine

Enlarged Glands Slow Beating Heart

Enlarged Thyroid Swelling of Ankles For Women Only

Eye Pain Cramps or Backache

Failing Vision MUSCLE & JOINT Excessive Flow

Far Sightedness Backache Hot Flashes

Frequent Colds Carpal Tunnel Syndrome Irregular Cycle

Gum Trouble Faulty Posture Lumps in Breast

Hay Fever Muscle Tightness/Spasm Menopausal Symptoms

Hoarseness Pain Between Shoulders Painful Menstrual Periods

Macular Degeneration Painful Ankle Previous Miscarriage

Nasal Drainage Painful Elbow Vaginal Discharge

Nasal Obstruction Painful Foot

Near Sightedness Painful Hand Are you Pregnant?

Nose Bleeds Painful Head ( ) Yes ( ) No

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).

1 - 1 2 3 Acidfoodsupset2 - 1 2 3 Get chilled, often3 - 1 2 3 "Lump"inthroat4 - 1 2 3 Dry mouth-eyes-nose5 - 1 2 3 Pulsespeedsaftermeal6 - 1 2 3 Keyed up-failtocalm7 - 12 3 Cutsheal slowly

GROUP ONE8-123GagEasilyI - 1 2 3 Unable to relax, startles easily

10 - 1 2 3 Extremities cold, clammy11 - 1 2 3 Strong light irritates12 - 1 2 3 Urine amounl reduced13 - 1 2 3 Heartpoundsafterretiring14 - 12 3 "Nervous"stomach

15 - 1 2 3 Appetite reduced16 - 1 2 3 Cold sweats often17 - 12 3 Fevereasilyraised18 - 1 2 3 Neuralgia-likepains19 - 1 2 3 Staring,blinkslittle20 - 12 3 Sourstomachfrequent

24 - 1 2 3 Eyesornosewatery25 - 12 3 Eyesblinkoften26 - 12 3 Eyelidsswollen, puffy

28 - 1 2 3 Always seem hungry;feels "lightheaded" often

GROUP TWO21 - 12 3 Jointstiffnessafterarising 29 - 12 3 Digestionrapid22- 12 3 Muscle-leg-toecrampsatnight 30 - 1 2 3 Vomitingfrequent23- 12 3 "Butterfly"stomach,cramps 31 - 1 2 3 Hoarsenessfrequent

27 - 12 3lndigestionsoonaftermeals 35 - 1 2 3 Difficultyswallowing

32 - 1 2 3 Breathing irregular33 - 1 2 3 Pulseslow; feels"irregulaf'34 - 1 2 3 Gagging reflex slow

36-l23Constipation,diarrhea alternating

37 - 12 3 "Slowstarted'38 - 1 2 3 Get"chilled"infrequently39 - 1 2 3 Perspireeasily40 - 1 2 3 Circulation poor,

sensitive to cold41 - 12 3 Subjecttocolds,

asthma, bronchitis

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

68 - 1 2 3 Bruise easily, "blackand blue" spots

69 - 1 2 3 Tendencytoanemia70 - 12 3 "Nosebleeds"frequent71 - 1 2 3 Noisesin head, or

"ringing in ears"72 - 1 2 3 Tension underthe

breastbone, or feelingof "tightness",worse on exertion

56-123

57-123

58-123

59-12360-123

61 -12362-123

SYMPTOM SURVEY FORM - Page 2

91 -12392-12393-12394-12395-12396-12397-123

84-12385-12386-12387-12388-12389-123

7374757677787980

81

82

-12 3 Dizziness- 12 3 Dryskin- 12 3 Burningfeet- 12 3 Blurredvision- 1 2 3 ltching skin and feet- 12 3 Excessivefallinghair- 1 2 3 Frequent skin rashes- 1 2 3 Bitter, metallic taste

in mouth in mornings-12 3 Bowel movements

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

hours after eating100 - 1 2 3 Burningstomach 103

sensations, eating relieves

(A)107-123lnsomnia108-l23Nervousness109 - 1 2 3 Can'tgainweight110 - 1 2 3 lntolerance to heat111 - 1 2 3 Highly emotional112-123 Flusheasily113 - 1 2 3 Nightsweats114 - 1 2 3 Thin, moistskin115 - 1 2 3lnwardtrembling116 - 1 2 3 Heart palpitates117 - 1 2 3 lncreased appetite without

weight gain1 18 - 1 2 3 Pulse fast at rest119 - 1 2 3 Eyelids and face twitch12O - 1 2 3 lrritable and restless121 - 1 2 3 Can't work under pressure

(B)122 - 1 2 3 lncrease in weight123 - 1 2 3 Decrease in appetite124 - 1 2 3 Fatigueeasily125-l2SRinginginears126 - 1 2 3 Sleepy during day127 * 123 Sensitivetocold128 - 1 2 3 Dryorscalyskin129-l2SConstipation130- 123 Mental sluggishness131 - 123 Haircoarse,fallsout132 - 1 2 3 Headaches upon arising

wear off during day133 - 1 2 3 Slow pulse, below 65134 - 1 2 3 Frequencyof urination135 - 1 2 3 lmpaired hearing136 - 1 2 3 Reduced initiative

- 1 2 3 lndigestion 112 - t hourafter 106eating; may be up to 3-4 hours

GROUP SEVEN

(c)137-123 Failingmemory138 - 1 2 3 Low blood pressure139 - 1 2 3 lncreased sex drive140 - 1 2 3 Headaches, "splitting

or rendering" type141 - 1 2 3 Decreased sugar

tolerance

(D)142 - 1 2 3 Abnormal thirst143 - 1 2 3 Bloating of abdomen144 - 1 2 3 Weight gain around

hips or waist145 - 1 2 3 Sex drive reduced

or lacking146 - 1 2 3 Tendency to ulcers,

colitis147 - 1 2 3 lncreased sugar

tolerance148 - 1 2 3 Women: menstrual

disorders149- 123 Younggirls:

lack of menstrualfunction

- 12 3 Mucouscolitisor"irritable bowel"

- 1 2 3 Gas shortly after eating- 12 3 Stomach"bloating"

after eating

(E)150-123Dizziness151*123Headaches152 - 1 2 3 Hotflashes153 - 1 2 3 lncreased blood

pressure154 - 1 2 3 Hair growth on face

or body (female)155-l2SSugarinurine

(not diabetes)156 - 1 2 3 Masculinetendencies

(female)

(F)157 - 1 2 3 Weakness, dizziness158 - 1 2 3 Chronic fatigue159 - 1 2 3 Low blood pressure160 - 1 2 3 Nails, weak, ridged161 - 123 Tendencytohives162 - 1 2 3 Arthritictendencies163 - 1 2 3 Perspiration increase164 - 1 2 3 Bowel disorders165 - 'l 2 3 Poorcirculation166- 123 Swollenankles167 - 1 2 3 Cravesalt168 - 1 2 3 Brown spots or

bronzing of skin169 * 1 2 3 Allergies-tendency

to asthma17O - 1 2 3 Weaknessaftercolds,

influenza171 - 123 Exhaustion-muscular

and nervous172 - 1 2 3 Respiratorydisorders

104

105

SYMPTOM SURVEY FORM - Page 3

173-123174-123175-123176-123177-123178-123179-123180 - 1 2 3181 - 1 2 3182-123183 - 1 2 3184-123185 - 1 2 3

186 - 1 2 3

187-123188-123189-123190-123191-123192-123193-123194-123195-123196-123197-123198-123199 - 1 2 3

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

FEMALE ONLY2OO - 1 2 3 Veryeasilyfatigued201 - 1 2 3 Premenstrual tension202- 123 Painful menses203 - 1 2 3 Depressed feelings

before menstruation204 - 1 2 3 Menstruation excessive

and prolonged205 - 1 2 3 Painful breasts206 - 1 2 3 Menstruatetoofrequently207 - 1 2 3 Vaginal discharge208 - 1 2 3 Hysterectomy/ovaries

removed209 - 1 2 3 Menopausal hotflashes210 * 1 2 3 Mensesscantyormissed211 - 1 2 3 Acne,worseatmenses212 - 1 2 3 Depression of long standing

MALE ONLY213 - 1 2 3 Prostate trouble214 - 1 2 3 Urination difficult

or dribbling215 - 1 2 3 Night urination frequent216- 123 Depression217 - 1 2 3 Painoninsideof

legs or heels218- 123 Feelingof incomplete

bowel evacuation219 - 1 2 3 Lack of energy220 - 1 2 3 Migrating aches and pains

221 - 1 2 3 Tiretooeasily222 - 1 2 3 Avoids activity223- 1 23 Legnervousnessatnight224 - 1 2 3 Diminishedsexdrive

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.

MALESAny 2 days during the month.

Date:Date:Date:Date:Date:Date:Date

Temperature:Temperature:Temperature:Temperature:Temperature:TemperatureTemperature:

BP SIT BP STANDPULSE SITSALIVA PH

PULSE STANDBLOOD TYPE

ooO-=(DoatC, I

fr8HOcraElo=. Ioto:Jo(t,ap)lo-+o0)3o=

oamImooItr,

3=f

J-a.(o)

oA'o

a!)o

A)

oo.

'-lc_oEofo

aox

NE

oEo0,*.ofIoa.o.o=ao

-=:coa

l,o(t,of

5oaoooo3E-0).fI

Ip)(oloa6'aC33q)

*

+o0)3of.:-!

aooo33oJo-0)*.ofoD)fo-1'o(oooI