Arlington Family Chiropractic Clinic
Chief Complaint
(History of Present Illness)
Patient Name: _____________________________________ Case: ____________ Date: _______________
Chief Complaint: __________________________________________________________________________
Body area(s) involved:
Condition:
□ New
□ Neck
□ Spine, Ribs, Pelvis
□ Recurring
□ Upper extremity
□ Exacerbation
□ Lower Extremity
□ Chronic
Mechanism of Onset:
□ Auto
□ Work . . .
□ Other . . .
□ No Injury
Symptoms:
(ask for accident history form)
□ Fall □ Lifting □ Overexertion □ Repetitive motion □ Other (accident form)
□ Etiology unknown □ Overexertion □ Repetitive use □ slept wrong □ slip or fall
□ Pain
□ Numbness
□ Stiffness
□ Weakness
Location: Left/Right/Bilateral ________________________________________________________________
Quality: □ Burning
□ Diffuse
□ Throbbing □ Tightness
□ Dull/Aching
□ Tingling
□ Localized
□ Sharp
□ Shooting
□ Stabbing
□ Radiating
□ Other ________________________
Level of Impairment due to symptoms (when resting)
0
1
2
3
4
5
6
7
8
9
10
6
7
8
9
10
Level of Impairment due to symptoms (when active)
0
1
2
3
4
5
Duration: Symptom(s) started: ________ Symptom(s) worsened: _______ Symptom(s) last occurred:______
Injury occurred: _________
Timing:
Accident occurred: __________
Worse in the: □ Morning □ Afternoon
Context: Better with: □ Warm Temp □ Cold Temp
□ Night
□ With Activity □ Constant
□ Intermittent
Worse with: □ Warm Temp □ Cold Temp □ Damp
Use the letters below to indicate the type and the location of your sensations right now.
A = Ache
B = Burning
P = Pins & Needles
N = Numbness
S = Stabbing
O = Other
History of Present Illness continued
Associated signs and symptoms: □ blurred vision □ depression □ dizziness □ headaches (see below)
□ irritability/mood swing □ localized tingling
Headaches:
Location: □ Occipital
Quality: □ Dull
Type:
□ Hat band
Other associated signs and symptoms:
□ Fatigue
□ Fever
□ Pale bluish skin □ Panic
□ Swelling
□ Tingling
□ Frontal
□ Sharp
□ Cluster
□ nausea □ ringing in the ears □ stiffness
□ Temporal
□ Throbbing
□ Migraine
□ Parietal □ Sinus
□ Stabbing □ Aura □ no Aura
□ Tension
□ Aches
□ Cold Limb
□ Heartburn
□ Muscle Spasm □ Nausea
□ Pins & Needles □ Runny nose
□ Vomiting
□ Dizziness □ Bruising
□ Stiffness
□ Numbness
□ Sweating
□ Weakness
Modifying factors: Symptoms better with: □ Activity □ Bending
□ Movement
□ OTC meds
□ RX meds
□ Rest
□ Standing
□ Twisting
□ Walking
□ Nothing helps
□ Cold
□ Heat
□ Stretching
□ Sitting
□Massage
Has anything that you have done, thus far, fixed your problem? Yes No
Condition’s effect on Job performance:
□ Mild painful (can do) □ Mod painful (limits ability)
□ Mod/Sev (limited duty)
□ Sev (can’t do limited duty)
Daily Activities: Effects of current condition on performance
Bending:
□ No effect
□ Mild painful (can do)
□ Mod painful (limited)
□ Sev unable to perform
Care for family
□ No effect
□ Mild painful (can do)
□ Mod painful (limited)
□ Sev unable to perform
Carrying groceries
□ No effect
□ Mild painful (can do)
□ Mod painful (limited)
□ Sev unable to perform
Sit to stand
□ No effect
□ Mild painful (can do)
□ Mod painful (limited)
□ Sev unable to perform
Climb stairs
□ No effect
□ Mild painful (can do)
□ Mod painful (limited)
□ Sev unable to perform
Driving
□ No effect
□ Mild painful (can do)
□ Mod painful (limited)
□ Sev unable to perform
Ext computer use
□ No effect
□ Mild painful (can do)
□ Mod painful (limited)
□ Sev unable to perform
Household chores
□ No effect
□ Mild painful (can do)
□ Mod painful (limited)
□ Sev unable to perform
Kneeling
□ No effect
□ Mild painful (can do)
□ Mod painful (limited)
□ Sev unable to perform
Lifting
□ No effect
□ Mild painful (can do)
□ Mod painful (limited)
□ Sev unable to perform
Bathing
□ No effect
□ Mild painful (can do)
□ Mod painful (limited)
□ Sev unable to perform
Dressing
□ No effect
□ Mild painful (can do)
□ Mod painful (limited)
□ Sev unable to perform
Sexual activities
□ No effect
□ Mild painful (can do)
□ Mod painful (limited)
□ Sev unable to perform
Sitting
□ No effect
□ Mild painful (can do)
□ Mod painful (limited)
□ Sev unable to perform
Sleep
□ No effect
□ Mild painful (can do)
□ Mod painful (limited)
□ Sev unable to perform
Standing
□ No effect
□ Mild painful (can do)
□ Mod painful (limited)
□ Sev unable to perform
Walking
□ No effect
□ Mild painful (can do)
□ Mod painful (limited)
□ Sev unable to perform
Yard work
□ No effect
□ Mild painful (can do)
□ Mod painful (limited)
□ Sev unable to perform
Other:__________________
□ No effect
□ Mild painful (can do)
□ Mod painful (limited)
□ Sev unable to perform
Other:__________________
□ No effect
□ Mild painful (can do)
□ Mod painful (limited)
□ Sev unable to perform
Medical/Family History: S = self
M = mother
F = father
Please indicate which PAST conditions have been experienced prior to present complaint by marking appropriate boxes.
S
M
F
□
□
□
Heart Disease
□
□
□
Arthritis
□
□
□
Cancer
□
□
□
Chest Pain
□
□
□
Diabetes
□
□
□
High Blood Pressure
□
□
□
Thyroid Disease
□
□
□
TIA/Stroke
Surgical History:
1.___________________________________________________
Date: ____________________
2.___________________________________________________
Date: _____________________
3.___________________________________________________
Date:______________________
4.___________________________________________________
Date:______________________
Are you allergic to any medications? Y/N If yes, what kind?________________________________
________________________________________________________________________________
Social History:
Do you smoke? Y/N If yes, how much?_______________________
Do you drink alcohol? Y/N If yes, how often and how much?____________________________
Do you use illicit drugs? Y/N, If yes, please describe?___________________________________
Certification and Assignment
To the best of my knowledge, the above information is complete and correct. I understand that it is my
responsibility to inform my doctor if I, or my minor child, ever have a change in health.
___________________________________________________________
Signature of Patient or Guardian
______________________
Date