Confidential Health History Form

     To help save you time I have provided a confidential health history form which will give me more information about your health status and give me a better feel for how I can best serve your needs. This form will take about 5 minutes to fill out.

     If at any time a question arises you are welcome to call our office at 949/492-7488 and ask for assistance. If you have any additional information that you feel would be helpful in evaluation of your health concerns such as blood / urine analysis, X rays, CT or MRI scans, or other laboratory testing, please bring that with you or you may fax us the information at 949/492-6658

*Your privacy is important to us.
We never have and never will disclose any private information to any third party under any circumstances.
Name:
Email Address:
Address :
City:
State:
Phone:
Best time to Contact:
Age:
Gender:
Current Weight:
Do you consider yourself:
Unintentional Weight loss or gain of 10lbs.
or more in the last 3 months?
Yes     No
Recent changes in your ability to:
See
Hear
Taste
Smell
feel hot or cold sensations
How did you hear about our site?

If 'Other' please let us know so we might thank them
Prior Chiropractic Care?
Yes    No:
If Yes, When?
Name of Doctor:
Results:
Describe Today's Chief Complaint:
Insurance Company:
Are your present problems due to an injury?
Yes: No:
If Yes, Where?
Have you made a report of your accident?
Are you now or have you ever been Disabled?
Yes     No
If Yes, When?
Have you retained an Attorney?
Yes     No
If Yes, Name and Address
When was your last:
 
Spinal Exam:
Disc Exam:
X-Ray Exam:
Lab Exam:
Last Physical:
Females: Pap Smear:
Breast Exam:
Habits:
 
Smoking:
Alcohol:
Coffee:
Exercise:
Have you had any of the following Diseases?
Appendicitis - Pneumonia - Rheumatic Fever - Tuberculosis - Whooping Cough
Anemia - Measles - Mumps - Chicken Pox - Diabetes - Cancer - Goiter
Heart Disease - Influenza - Pleurisy - Alcoholism - Venereal Infection - Arthritis
- Polio - Epilepsy - Mental Disorders - Lumbago - Eczema - AIDS
Family History:
 
Mother:
Diabetes - Heart - Kidney - Cancer
Father:
Diabetes - Heart - Kidney - Cancer
Sisters:
Diabetes - Heart - Kidney - Cancer
Brothers:
Diabetes - Heart - Kidney - Cancer
Signs and Symptoms: A complete history will facilitate care

General Symptoms :
Headache: Previously - Presently
Fever: Previously - Presently
Chills: Previously - Presently
Night Sweats: Previously - Presently
Fainting: Previously - Presently
Dizziness: Previously - Presently
Convulsions: Previously - Presently
Loss of Sleep: Previously - Presently
Fatigue: Previously - Presently
Nervousness: Previously - Presently
Weight Loss: Previously - Presently
Allergy's: Previously - Presently
Wheezing: Previously - Presently
Neuralgia: Previously - Presently
Numbness or pain in arms/legs/hands:
Previously - Presently

Gastro-Intestinal:
Poor Appetite: Previously - Presently
Poor Digestion: Previously - Presently
Excessive Hunger: Previously - Presently
Belching or Gas: Previously - Presently
Nausea: Previously - Presently
Vomiting: Previously - Presently
Vomiting Blood: Previously - Presently
Pain over Stomach: Previously - Presently
Constipation: Previously - Presently
Diarrhea: Previously - Presently
Colon Trouble: Previously - Presently
Hemorrhoids: Previously - Presently
Liver Trouble: Previously - Presently
Jaundice: Previously - Presently
Gall Bladder Trouble; Previously - Presently

Eye/Ears/Nose/Throat:
Poor Vision: Previously - Presently
Crossed Eyes: Previously - Presently
Pain in Eyes: Previously - Presently
Deafness: Previously - Presently
Earache: Previously - Presently
Ear Noises: Previously - Presently
Ear Discharges:
Previously - Presently
Nasal Obstruction: Previously - Presently
Nose Bleeds: Previously - Presently
Sore Throats: Previously - Presently
Hoarseness: Previously - Presently
Hay Fever: Previously - Presently
Asthma: Previously - Presently
Frequent Colds: Previously - Presently
Enlarged Thyroid: Previously - Presently
Tonsillitis: Previously - Presently
Sinus Trouble: Previously - Presently

Respiratory:
Chronic Cough: Previously - Presently
Spitting Blood: Previously - Presently
Spitting Phlegm: Previously - Presently
Chest Pain: Previously - Presently
Difficulty breathing: Previously - Presently


Genito-Urninary:
Frequent Urination: Previously - Presently
Painful Urination: Previously - Presently
Blood in Urine: Previously - Presently
Kidney Infection: Previously - Presently
Bed Wetting: Previously - Presently
Prostate Trouble: Previously - Presently
Inability to control Urine:
Previously - Presently

Muscles & Joints:
Weakness: Previously - Presently
Twitching: Previously - Presently
Stiff Neck: Previously - Presently
Backache: Previously - Presently
Swollen Joints: Previously - Presently
Tremors: Previously - Presently
Foot Trouble: Previously - Presently
Pain in Tailbone: Previously - Presently
Pain Between Shoulders: Previously - Presently
Hernia: Previously - Presently
Spinal Curvature: Previously - Presently

Cardio-Vascular:
Rapid Heart: Previously - Presently
Slow Heart: Previously - Presently

High Blood Pressure: Previously - Presently
Low Blood Pressure: Previously - Presently
Pain over Heart: Previously - Presently
Heart Trouble: Previously - Presently
Swelling Ankles: Previously - Presently
Poor Circulation: Previously - Presently
Varicose Veins: Previously - Presently
Strokes: Previously - Presently

Skin or Allergies:
Skin Eruptions: Previously - Presently
Itching: Previously - Presently
Bruise Easily: Previously - Presently
Dryness: Previously - Presently
Boils: Previously - Presently
Sensitive Skin: Previously - Presently
Hives or Allergy: Previously - Presently
Eczema: Previously - Presently


FOR WOMEN ONLY:
Painful Periods: Previously - Presently
Excessive Flow: Previously - Presently
Irregular Cycle: Previously - Presently
Hot Flashes: Previously - Presently
Cramps or Backache: Previously - Presently
Miscarriage: Previously - Presently
Vaginal Discharge: Previously - Presently
Pregnant: Previously - Presently
Last Pap:
By Whom:

OPERATIONS and PROCEDURES:

Vaccinations: Date
Tonsillectomy: Date
Back Operation: Date
Tubes in Ears: Date
Appendectomy: Date
Female Organs: Date
Rectal Surgery: Date
Sinus: Date
Hernia: Date
Thyroid: Date
Stomach: Date
Other: Date
Recent Dental: Date



List any accidents or falls/When:


List any Broken bones/When:


Ever on Crutches/When:


Any Spinal Taps or Injections/When:


Ever Knocked Unconscious/When:


Ever had a Lapse of Memory/When:

Drugs and Medicines:
Over the counter, Prescription, and Recreational

Check the following statements that apply:
Occasionally or frequently skip meals
Suffer from fatigue
Currently overweight
Crave sweets or carbohydrates
Crave stimulants, such as caffeine or soft drinks
Suffer from chronic pain
Suffer from headaches
Activity Level – Check Your Current Level
of Work or Lifestyle:
Level 1 – Very Light Work: Sitting, standing,
driving, reading, computer, etc.
Level 2 – Light Work: Light housework, labor,
childcare, mechanic, some sitting, etc.
Level 3 – Moderate Work: Heavy gardening,
housework, labor, no sitting, etc.
Level 4 – Heavy Work: Heavy manual labor,
construction, digging, etc.
Exercise Level – Check Your Current
Level of Exercise:
None
Level A – Light Exercise: 1-3 times per week,
easy pace, stretching,walking, etc.
Level B – Moderate Exercise: 2-3 times
per week, moderate pace, some weights, etc.
Heavy Exercise - 3-4 times per week,
vigorous pace,weights, fast running, etc.
Balance Eating – Check Which Apply:
Mixed food diet (animal and vegetable sources)
Vegetarian
Vegan
Salt Restriction
Fat Restriction
Starch/carbohydrate restriction
The Zone Diet
Total calorie restriction

Specific food restrictions of:
dairy wheat eggs
soy corn all gluten
Other
Servings per day:
Fruits (citrus, melons, etc.)

Dark green or deep yellow/orange vegetables
Grains (unprocessed)
Beans, peas, legumes
Dairy, eggs
Meat, poultry, fish
Eating Frequency – Check Which Apply:
Skip breakfast or other meals
Three meals/day
Two meals/day
One meal/day
Graze-small frequent meals (how many/day)
Generally eat on the run
Exercise Frequency and Schedule –
Check Which Apply:
5-7 days per week
3-4 days per week
1-2 days per week
45 min or more duration per workout
30-45 min or more duration per workout
Less than 30 min
Use of personal trainer
Member of fitness club
Own exercise equipment
Walk: days/week

Run, jog, other aerobic: days/week

Weight lift: days/week
Stretch: days/week
Yoga: days/week
Other: days/week
Stress Habits – Check Which Apply:
Level of stress you are experiencing on a scale
of 1 to 10 (1 being the lowest)
Is your job associated with potentially harmful chemicals,
pesticides, radioactivity or solvents:
Yes     No
Do you suffer from insomnia/sleep disorders?
Yes     No
Do you often abruptly awake from sleep?
Yes     No
Do you suffer from depression/mood swings?
Yes     No
Supplement Use Habits – Check Which Apply:
Multivitamin/mineral
Vitamin C
Vitamin E
EPA/DHA
GLA (Evening primrose)
Calcium, source
Magnesium
Zinc
Minerals, describe
Friendly flora (acidophilus)
Digestive enzymes
Amino acids
CoQ10
Antioxidants (lutein, resveritol, etc.)
Herbs – teas
Herbs – extracts
Chinese herbs
Ayurvedic herbs
Homeopathy
Bach flowers
Superfoods (bee pollen, phytonutrient blends)
Liquid meals (Ensure)
Other
Energy – Vitality
I’d like to:
Have more energy
Have longer endurance
Have more motivation
Sleep better
Be less tired after lunch
Feel more vital
Regain vitality and vigor of my younger years
Get less colds and flu
Get rid of allergies
Not use so many over the counter drugs
Stop using laxatives
Be free of pain
Longevity – Life Enrichment
I’d like to:
Reduce my risk of degenerative disease
Slow down accelerated aging
Monitor biomarkers of aging
Have less facial wrinkles
Maintain a healthier life longer
Change from a “treating-illness”orientation
to a creating wellness lifestyle
Body Composition – Fat/Muscle
I’d like to:
Be stronger
Be thinner
Be more muscular
Burn more body fat
Be more flexible
Lose weight
Stress Reduction – Mental/Emotional
I’d like to:
Be happier
Be less depressed
Be less moody
Be less indecisive
Be more focused
Think more clearly
Improve my memory
Learn how to reduce stress
Learn how to meditate
Additional Comments: