302 West Main Street, Suite 204, Avon, CT 06001

Phone: 1-860-679-0430

Fax: 1-860-679-0431

61 Maple Avenue, Suite 2, Canton, CT 06019

Phone: 1-860-352-2463

Fax: 1-860-352-8247

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Medical History Client Form

Printable Form at Bottom of Page

Have you received any of the following treatments in the past year?

Chiropractic                                       Speech Therapy         

Yes   No                                               Yes   No

 

Home Care Physical Therapy          Occupational Therapy

Yes   No                                              Yes   No

 

Please list any allergies:

______________________________________   Response: ___________________________________

______________________________________   Response: ___________________________________

Please list any surgeries you have had:

_______________________________________________    Date: ______________________________

_______________________________________________    Date: ______________________________

_______________________________________________    Date: ______________________________

 

Please list any medications you are currently taking or attach a medication list:

            Drug                               Dose                               Frequency                                Reason

    ______________            _______________                 _______________                 _______________

    ______________            _______________                 _______________                 _______________​

    ______________            _______________                 _______________                 _______________​

Have you ever taken steroid medication for any medical condition?    Yes   No

Have you ever taken blood thinners or anticoagulants for any medical condition?    Yes   No

 

Are you currently pregnant?    Yes   No

 

Do you currently exercise?    Yes   No

If yes, what types and how often?   

____________________________________________________________________________________

 

 

Weight: _________________lbs Height: __________ft_________in

Client/Patient/Guardian Signature:

________________________________________________                          Date: _________________

 

                                                                     Name: __________________________________________   

 

 

THE FOLLOWING ITEMS ARE SPECIFIC TO YOUR CURRENT INJURY/CONDITION

 

When did your current symptoms start  __________________________________________________

What do you think caused your symptoms? ______________________________________________

 

My symptoms are currently:            Getting Better          Getting Worse         Staying the Same

 

I should avoid all physical activities that might make my pain worse: 

                Disagree                    Agree             Unsure

 

Treatment received so far for this problem, with dates (chiropractic, injections, etc):

______________________________________________________________________________________

Please list any tests performed for this problem, with dates (x-ray, MRI, labs, etc):

______________________________________________________________________________________

 

Have you ever had this problem before?    Yes   No       Did you have treatment?    Yes   No

 

How long did it take for you to feel better?    ______________________________________________

 

Are you currently able to sleep at night due to your symptoms?

                No problem sleeping                                 Difficulty falling asleep

                Awakened by pain                                      Sleep with medication

 

When are your symptoms worse?   Morning     Afternoon     Evening     Night     After exercise

When are your symptoms better?   Morning     Afternoon     Evening     Night     After exercise

How often do you experience your symptoms?   Constantly    Frequently   Occasionally

 

 

Using the 0 to 10 scale with 0 being “no pain” and 10 being the

“worst pain imaginable” please describe:

 

                                                             ______/10

 

                                                             ______/10

 

Please indicate on the diagram to the right where you feel your pain.

 

 

Your current level of pain right now: 

The best your pain has been during the last 24 hours:

The worst your pain has been during the past 24 hours: ______/10

 

 

Client/Patient/Guardian Signature:

________________________________________________     Date: ______________________________

􀁸 Headaches   

􀁸 Weight loss/gain  

􀁸 Numbness/tingling  

􀁸 Heartburn/indigestion           􀁸 Diarrhea or constipation   􀁸 Cough  

􀁸 Numbness/tingling   

􀁸 Muscle weakness   

􀁸 Dizziness/lightheaded  

􀁸 Heartburn/indigestion           􀁸 Difficulty swallowing    

 􀁸 Bowel/bladder changes 

􀁸 Diarrhea or constipation   

􀁸 Falls   

􀁸 Fainting  

􀁸 Cough

􀁸 Fatigue

􀁸 Infection  

​Name:  __________________________________________        Date:  __________________________

Have you RECENTLY noted any of the following? (check all that apply)

Have you EVER been diagnosed with any of the following conditions? (check all that apply)

􀁸 Allergies   

􀁸 Anemia ¨Anxiety  

􀁸 Arthritis  

􀁸 Bone/joint infection          􀁸 Asthma 

􀁸 Autoimmune disorder 

􀁸 Cancer  

􀁸 Cardiac/heart problems

􀁸 Arrhythmia        

􀁸 Chest pain/angina 

􀁸 Pacemaker or defibrillator

􀁸 Chemical dependency  

􀁸 Circulation/vascular problems 

􀁸 Blood or clotting disorders       􀁸 Raynaud’s disease

􀁸 Depression  

􀁸 Diabetes

􀁸 Dizzy spells

􀁸 Emphysema/bronchitis

􀁸 Lung problems

􀁸 Pneumonia

􀁸 Fibromyalgia

􀁸 Fractures

􀁸 Gallbladder problems

􀁸 Headaches

􀁸 Hearing impairment

􀁸 Hepatitis

􀁸 Liver problems

􀁸 High cholesterol

􀁸 High blood pressure

􀁸 Low blood pressure

􀁸 Sexually transmitted infection

􀁸 Pelvic inflammatory disease

􀁸 HIV/AIDS

􀁸 Incontinence

􀁸 Kidney problems

􀁸 Urinary tract/bladder infection

􀁸 Metal implants

􀁸 MRSA

􀁸 Multiple sclerosis

􀁸 Muscular disease

􀁸 Osteopenia or osteoporosis

􀁸 Parkinson’s

􀁸 Rheumatoid arthritis

􀁸 Seizures/epilepsy

􀁸 Smoking/tobacco use

􀁸 Speech problems

􀁸 Stroke

􀁸 Thyroid disease

􀁸 Tuberculosis

􀁸 Vision problems

Has anyone in your immediate family (parents, brothers, sisters) EVER been diagnosed with any of the following conditions? (check all that apply)

􀁸 Cancer   

􀁸 Heart problems

􀁸 High blood pressure

􀁸 Diabetes

􀁸 Stroke

􀁸 Depression

􀁸 Tuberculosis 

􀁸 Thyroid Problems

􀁸 Blood Clots

                            Name:  ____________________________________       2

During the past month have you been feeling down, depressed or hopeless?    Yes   No

During the past month have you been bothered by having little interest or pleasure in doing things?    Yes   No

Is this something with which you would like help?    Yes   No

Do you ever feel unsafe at home or has anyone hit you or tried to injure you in any way?    Yes   No

To print Medical History Form click here: