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:____________________