IMAGINE CHIROPRACTIC
1812 Becketts Ridge Dr, Hillsborough, NC 27278
(919) 932-0222
CONFIDENTIAL PATIENT HEALTH RECORD
DATE: ______/______/______
PERSONAL INFORMATION
Name: __________________________________________
Address: __________________________________________
City: ___________________________________________
State: ___________
Phone (Home): ______________________
Cell: _______________________
Date of Birth: ______/______/______
Age: __________
Sex:
Zip: _____________________
Male ____
Female ____
Soc. Sec. No.: ___________________________________
E-Mail Address: _______________________________
Employer’s Name: _________________________________
Address: _________________________________________
Employer’s Phone: ________________________________
Type of Work: ____________________________________
Marital Status:
S
M
P
D
W
Names of Children & Ages: __________________________________________________
SPOUSAL INFORMATION
Name: ___________________________________________
Soc. Sec. No: ______________________________________
Employer’s Name: _________________________________
Address: __________________________________________
Employer’s Phone: _________________________________
Type of Work: _____________________________________
EMERGENCY CONTACT INFORMATION
Name: __________________________________________
Address: __________________________________________
Phone: __________________________________________
Relationship: ______________________________________
Injury (ies): Mark or List All Injuries. Write the DATE of the Injury immediately afterward.
ft tissue injury (mild)
surgeries type:
Current Medication /Vitamins(s):
Medication/Vitamins
List ANY/ALL medications you are CURRENTLY taking. Be Specific.
Dosage
For What Condition?
How long have
you been taking this?
THANK YOU
CONFIDENTIAL PATIENT HEALTH RECORD
Following are questions concerning your condition, please answer ALL questions
Who may we thank for referring you? ____________________________________________________________________________________
Reasons for consulting our office: _______________________________________________________________________________________
Current health complaints:
1. _____________________
2. _____________________
3. _____________________
When did the problem begin?
_______________________
_______________________
_______________________
What makes pain better?
(sitting, standing, walking, etc.)
_______________________
_______________________
_______________________
What makes pain worse?
(sitting, standing, walking, etc.)
_______________________
_______________________
_______________________
What is your level of pain?
(0-10 with 10 being worst)
_______________________
_______________________
_______________________
What type of pain are you having? (dull, achey
sharp, shooting, stabbing, burning, etc.)
_______________________
_______________________
_______________________
Does your pain radiate anywhere?
_______________________
_______________________
_______________________
Where does it hurt the most?
(Central or to Left or Right side)
_______________________
_______________________
_______________________
When does it hurt the most?
_______________________
_______________________
_______________________
Is the pain constant, frequent,
intermittent or occasional?
_______________________
_______________________
_______________________
Have you had similar problems before?
_______________________
_______________________
_______________________
If so, for how long?
_______________________
_______________________
_______________________
CHILDHOOD Illness (es):
LIST all health conditions. CIRCLE all CURRENT conditions.
es
Family History:
CRCLE all that apply below. List any specific conditions past or present after has/had:
father
mother
son (s)
ased
y developed
daughter(s)
brother(s)
sister(s)
THANK YOU