Patient Health Questionnaire

Patient Name:

Date:

1. Describe your current symptoms (Begin with what bothers you the most):

2. When did your symptoms begin?

3. What activities make your symptoms worse?

Ice

Heat

Rest

Activity

Sitting

Standing

Medication

Other

4. What activities make your symptoms better?

Ice

Heat

Rest

Activity

Sitting

Standing

Medication

Other

5. What describes the nature of your symptoms?

Sharp

Dull Ache

Numb

Shooting

Burning

Tingling

6. Draw the location of your symptoms on Diagram (This done once you get to the Chiropractors Office)

Indicate where you have pain or other symptoms

7. What describes the severity of your symptoms?

None 1	2	3	4	5	6	7	8	9	10 Severe

8. How are your symptoms changing ?

Getting Better

Not Changing

Getting Worse

9. Who else have you seen for your current symptoms?

No One

Other Chiropractor

Medical Doctor

Physical Therapist

This Office

Other:

10. b. What tests have you had for your symptoms?

None

X-rays date :

CT Scan Date:

MRI date:

Other date:

11. What other forms of care have you tried for your current complaint?

Nothing

Muscle Relaxer

Advil/Tylenol/Aleve, etc

Physical Therapy

Pain Medication	Ice/Heat	Injections
Other:

12. What do you feel caused your symptoms?

Fall	Lifting	Work
Car Accident	Don't Know	Other:

13. What activities are effected by your symptoms?

Work/School	Sleeping	Driving/Riding in Car	Golf	Exercising
Walking	Running	House Work	Yard Work	Other:

14. Have you had similar symptoms in the past?

Yes

When:

No

15. If yes, whom did you see?

No One	Medical Doctor	This Office
Other Chiropractor	Physical Therapist	Other:

16. What is your occupation?

Professional/Executive	Laborer	Retired
White Collar/Secretarial	Homemaker	Other:

Tradesperson

F/T Student

17. What type of regular exercise do you perform?

None

Light

Moderate

Strenuous

For each of the conditions listed below, place a check in the PAST column if you have had the condition in the past. If you have the conditions listed, place a check in the PRESENT column. Many of the following conditions respond to chiropractic and acupunture.

18.	19.
PAST	PRESENT	PAST	PRESENT	PAST	PRESENT
1.	Headaches	21.	High Blood Pressure	43.	Diabetes
2.	Neck Pain	22.	Heart Attack	44.	Excessive Thirst/Urination
3.	Upper Back Pain	23.	Chest Pains	45.	Thyroid Disorder
4.	Mid Back Pain	24.	Stroke	46.	Smoking/Tobacco Use
5.	Low Back Pain	25.	Angina	47.	Drug/Alcohol Depecdence
6.	Shoulder Pain	26.	Kidney Stones	48.	Food Allergies
7.	Elbow/Upper Arm Pain	27.	Kidney Disorder	49.	Depression
8.	Wrist Pain	28.	Bladder Infection	50.	Frequent Illness
9.	Hand Pain	29.	Painful Urination	51.	Epilepsy
10.	Hip/Upper Leg Pain	30.	Loss of Bladder Control	52.	Dermatitus/Eczema/Rash
11.	Knee/Lower Leg Pain	31.	Prostate Problems	53.	HIV/AIDS
12.	Ankle/Foot Pain	32.	Abnormal Weight Gain/Loss	Females	Only
13.	Jaw Pain/TMJ	33.	Loss of Appetite	54.	Hot Flashes
14.	Joint Swelling/Stiffness	34.	Abdominal Pain	55.	Horomone Replacement
15.	Arthritis	35.	Ulcer	56.	Birth Control Pills
16.	Rhuematoid Arthritis	36.	Hepatitis	57.	Painful Periods/Cramps
17.	General Fatigue	37.	Liver/Gall Bladder Disorder	58. YES	NO (ARE YOU PREGNANT?)
18.	Ringing in Ears	38.	Cancer		Estimated Due Date
19.	Visual Disturbances	39.	Tumer	Other	Health Problems
20.	Dizziness	40.	Asthma	59.

		41.	Chronic Sinusitus	60.
		42.	Seasonal Allergies	61.

20. Primary Care Physician

20b. Date of Last Medical Physical

21.Indicate if an immediate family member has had any of the following:

Rheumatoid Arthritis

Heart Problems

Diabetes

Cancer

Lupus

Other:

22. List all prescription and over-the-counter medications, nutritional/herbal supplements you are taking:

23. List all the surgical procedures you have had and times you have been hospitalized:

24. Detail any history of trauma to head, neck, or back (automobile accidents, sports injuries, work-related accidents, etc):

Fill out this section once you get to the office:

Patient Signature____________________________________

Date______________________