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