Dr. Ian Rainey, D. C.
545 Metro Place S.  Suite 100  Columbus, OH 43016  (614) 987-8390
Confidential Patient Health Record - PERSONAL HISTORY
Date: _____________ Family Doctor: _________________________ Who referred you to this office:_____________________
Last Name:______________________ First Name:____________________
Date of Birth:_________________
Age:_______
Middle Initial: ____
Gender: ___M ___F Social Security #:_____________________________
Marital Status: Married/Single/Widowed/Divorced/Separated
Street Address:___________________________________________________________________________________________
City:__________________________ State:________
Zip Code:_________________
Home Phone:___________________________ Cell Phone :___________________________ Preferred Phone _____________
Employment Status: ____________________________________ Professional Title:___________________________________
Email:______________________________________ Employer Name & Phone #: _____________________________________
Name of Emergency Contact:_______________________ Relationship:______________ Phone Number__________________
Name of Spouse (if applicable):________________________
Spouse’s Employer:___________________________________
Names and Ages of Children________________________________________________________________________________
Who is Responsible for your bill: You and ___Cash/Health Savings Account
___Health Insurance __Auto Insurance
Health Insurance Company: ________________________________ Insurance ID #:___________________________________
If insurance is under a different name: ____________________________________ Date of Birth: _________________________
CURRENT HEALTH CONDITION
Purpose of this appointment:_______________________________________________________________________________
Other Doctors seen for this condition: ____Yes
___No
Who?_____________________________________________
Type of Treatment:________________________________
Results:___________________________________________
When did this Condition begin?______________________
Has this condition occurred before? ___Yes ___No
Is Condition: ___Job Related ___Auto Accident ___Home Injury ___Fall ___Other:______________________________
Date of Accident:__________________________________
Time of Accident:___________________________________
Have you made a report of your Accident to your Employer: ___Yes ___No
Insurance Company ___Yes ___No
Drugs you now take: ___Nerve Pills ___Pain Killers/Muscle Relaxers ___Blood Pressure Medicine
___Sleep Aids
___Insulin ___Other____________________________________________________________________________________
Do you wear a shoe lift? ___Yes ___No
Have you ever worn a spinal brace? ___Yes
___No
Do you suffer from any Condition other than that which you are now consulting us?___________________________________
______________________________________________________________________________________________________
PAST HEALTH HISTORY
Please check and describe:
Major Surgery/Operations:
___Appendectomy
___Tonsillectomy
___Gall Bladder
___Hernia
___Back Surgery
___Broken Bones ___Other______________________________________________________________________________
Smoker? Current/Former/Never If yes, explain:_____________________________________________________________
Major Accident or Falls:___________________________________________________________________________________
______________________________________________________________________________________________________
Hospitalization (Other than Above):_________________________________________________________________________
______________________________________________________________________________________________________
Previous Chiropractic Care:
___None
___Doctor’s Name & Approximate Date of Last Visit: ________________________
Dr. Ian Rainey, D. C.
545 Metro Place S.  Suite 100  Columbus, OH 43016  (614) 987-8390
PATIENT INTAKE FORM
Patient Name: _____________________________ Date: _______________
1. Is today's problem caused by: ___Auto Accident
___ Workman's Compensation
___ Other
If “Other”, please list cause _______________________________________________
Chief Complaint: Indicate on the drawings below where you have pain/symptoms
Dr. Ian Rainey, D. C.
545 Metro Place S.  Suite 100  Columbus, OH 43016  (614) 987-8390
2. What concerns you the most about your problem; what does it prevent you from doing? Please
specify each symptom next to each selection (ex: knee/back, neck, etc)
□ It could be Serious
□ It isn’t going away
□ It is getting worse
□ It is affecting daily activities
3. How would you describe the type of pain? Please specify each symptom next to each selection
(ex: knee/back, neck, etc)
□ Sharp
□ Numb
□ Dull
□ Tingly
Dr. Ian Rainey, D. C.
545 Metro Place S.  Suite 100  Columbus, OH 43016  (614) 987-8390
□ Diffuse
□ Sharp with motion
□ Achy
□ Shooting with motion
□ Burning
□ Stabbing with motion
□ Shooting
□ Electric like with motion
□ Stiff
□ Other:___________________
4. How often do you experience your symptoms? Please specify each symptom next to each
selection (ex: knee/back, neck, etc)
□ Constantly (76-100% of the time)
□ Occasionally (26-50% of the time)
□ Frequently (51-75% of the time)
□ Intermittently (1-25% of the time)
5. Using a scale from 0-10 (10 being the worst), how would you rate your problem? Please specify
each area of pain next to each selection (ex: knee,back, neck, etc)
0 1 2 3 4 5 6
7 8
9 10 (Please circle)
6. How are your symptoms changing with time? Please specify each symptom next to each
selection (ex: knee/back, neck, etc)
□ Getting Worse
□ Staying the Same
□ Getting Better
7. Do you consider this problem (s) to be severe?
□ Yes
□ Yes, at times
□ No
8. What aggravates your problem? Please specify each area of pain next to each selection (ex:back,
neck, etc)
□ Standing
□ Sitting
□ Walking
□ Sleeping
□ Driving
□ Other ___________________________________
9. What makes the pain feel better?
□ Rest
□ Heat
□ Ice
□ Pain Medications
□ Activity
□ Other ___________________________________
10. Who else have you seen for your problem?
□ Chiropractor
□ Neurologist
□ Primary Care Physician
□ ER physician
□ Orthopedist
□ Other:_____________
□ Massage Therapist
□ Physical Therapist
□ No one
11. How long have you had this problem? Please specify each symptom next to each selection (ex:
knee/back, neck, etc) _________________________________________________________________
12. How much has the problem interfered with your work? Please specify each symptom:
□ Not at all
□ A little bit
□ Moderately
□ Quite a bit
□ Extremely
13. How much has the problem interfered with your social activities? Please specify each symptom:
□ Not at all
□ A little bit
□ Moderately
Quite a bit
□ Extremely
14. What is your: Height___________
Weight _____________
Date of Birth ___________
15. How would you rate your overall Health?
□ Excellent
□ Very Good
□ Good
□ Fair
□ Poor
16. What type of exercise do you do?
□ Stenuous
□ Moderate
□ Light
□ None
17. How do you want chiropractic to change your life?
______________________________________________________________________________________
18. What things are you unable to do that you would like to be able to do (i.e. pick up grand children,
comb your hair, tie your shoes, have more energy)?
1.) __________________________________________________________
2.) __________________________________________________________
3.) __________________________________________________________
19. Indicate if you have any immediate family members with any of the following:
□ Rheumatoid Arthritis
□ Diabetes
□ Lupus
□ Heart Problems
□ Cancer
□ ALS
20. For each of the conditions listed below, place a check in the "past" column if you have had the
condition in the past. If you presently have a condition listed below, place a check in the "present"
Dr. Ian Rainey, D. C.
545 Metro Place S.  Suite 100  Columbus, OH 43016  (614) 987-8390
column.
Past Present
Past Present
Past Present
□
□ Headaches
□
□ High Blood Pressure
□
□ Diabetes
□
□ Neck Pain
□
□ Heart Attack
□
□ Excessive Thirst
□
□ Upper Back Pain
□
□ Chest Pains
□
□ Frequent Urination
□
□ Mid Back Pain
□
□ Stroke
□
□ Smoking/Tobacco Use
□
□ Low Back Pain
□
□ Angina
□
□ Drug/Alcohol Dependance
□
□ Shoulder Pain
□
□ Kidney Stones
□
□ Allergies
□
□ Elbow/Upper Arm Pain
□
□ Kidney Disorders
□
□ Depression
□
□ Wrist Pain
□
□ Bladder Infection
□
□ Systemic Lupus
□
□ Hand Pain
□
□ Painful Urination
□
□ Epilepsy
□
□ Hip Pain
□
□ Loss of Bladder Control □
□ Dermatitis/Eczema/Rash
□
□ Upper Leg Pain
□
□ Prostate Problems
□
□ HIV/AIDS
□
□ Knee Pain
□
□ Abnormal Weight Gain/Loss
□
□ Ankle/Foot Pain
□
□ Loss of Appetite
For Females Only
□
□ Jaw Pain
□
□ Abdominal Pain
□
□ Birth Control Pills
□
□ Joint Pain/Stiffness
□
□ Ulcer
□
□ Hormonal Replacement
□
□ Arthritis
□
□ Hepatitis
□
□ Pregnancy
□
□ Rheumatoid Arthritis
□
□ Liver/Gall Bladder Disorder
□
□ Cancer
□
□ General Fatigue
□
□ Tumor
□
□ Muscular Incoordination
□
□ Asthma
□
□ Visual Disturbances
□
□ Chronic Sinusitis
□
□ Dizziness
□
□ Other:____________________________
21. List all prescription medications you are currently taking (we can make a copy):
______________________________________________________________________________________
22. List all of the over-the-counter medications you are currently taking (we can make a copy):
______________________________________________________________________________________
23. What activities do you do at work? Please check the appropriate boxes.
□ Sit:
□ Most of the day
□ Half the day
□ Stand:
□ Most of the day
□ Half the day
□ Computer work:
□ Most of the day
□ Half the day
□ On the phone:
□ Most of the day
□ Half of the day
□ Drives:
□ Most of the day
□ Some of the day
□ Activity:
□ Performs manual labor
□ Reads a lot
□ A little of the day
□ A little of the day
□ A little of the day
□ A little of the day
□ A little of the day
□ Travels frequently
24. What activities do you do outside of work? (ex: Walk, Run, Swim, Garden, Tennis, Lift weights)
______________________________________________________________________________________
25. Have you had significant past trauma? List date and trauma type: □ No
□ Yes
______________________________________________________________________________________
26. Anything else pertinent to your visit today? If so, please list in detail:
______________________________________________________________________________________
______________________________________________________________________________________
27. Do you attest that the above information is accurate and complete to the best of your ability?
□ Yes
□ No
27. Patient Signature________________________________________ Date:____________________
Download

New Patient Intake Form