Fillable NEW PATIENT HEALTH HISTORY FORM (Dr. Kate Keville)

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NEW PATIENT HEALTH HISTORY FORM (Dr. Kate Keville)

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NEW PATIENT HEALTH HISTORY FORM
In order to provide you the best possible care, please complete this form
and bring it to your first appointment. All information is strictly CONFIDENTIAL
TODAY’S DATE:
PATIENT DATA
FIRST NAME:
LAST NAME:
DATE OF BIRTH:
EMAIL:
MOBILE #:
PHONE 2:
May we contact you via e-mail? ☐ YES ☐ NO
Yes ☐ NO
How did you hear about our practice?
ADDRESS:
CITY:
STATE:
ZIP CODE:
EMERGENCY CONTACT:
PHONE:
RELATION:
CURRENT COMPLAINTS
DESCRIBE INJURY OR SYMPTOMS:
DATE OF INJURY OR DATE SYMPTOMS APPEARED:
HAVE YOU EVER HAD THE SAME CONDITION?
☐ YES ☐ NO
IF YES, WHEN:
DO YOU EXPERIENCE PAIN EVERYDAY?
☐ NO
☐ YES
DO YOUR SYMPTOMS INTERFERE WITH DAILY LIFE?
☐ NO
☐ YES
DOES YOUR PAIN WAKE YOU UP AT NIGHT?
☐ NO
☐ YES
ARE YOUR SYMPTOMS WORSE DURING CERTAIN TIMES OF DAY?
☐ NO
☐ YES
DO CHANGES IN WEATHER AFFECT YOUR SYMPTOMS?
☐ NO
☐ YES
WHAT ACTIVITIES AGGRAVATE YOUR SYMPTOMS?
MEDICAL HISTORY
HAVE YOU BEEN TREATED FOR ANY CONDITION(S) IN THE LAST YEAR? ☐ NO ☐ YES
IF YES, PLEASE DESCRIBE:
DATE OF LAST PHYSICAL EXAM:
IS THERE A CHANCE YOU MIGHT BE PREGNANT? ☐ YES ☐ NO
HAVE YOU HAD X-RAYS TAKEN? ☐ YES ☐ NO If YES, where:
WHAT MEDICATIONS ARE YOU CURRENTLY TAKING AND FOR WHAT CONDITIONS? (PLEASE LIST
DOSAGE AND AMOUNTS)
WHAT VITAMINS, MINERALS, SUPPLEMENTS AND/OR HERBS DO YOU CURRENTLY TAKE? (PLEASE LIST
ITEM, DOSAGE, FREQUENCY AND FOR WHAT CONDITION(S):
FAMILY HISTORY
Family Members – List present and past health conditions (examples: heart disease, cancer, stroke,
diabetes arthritis, etc.)
Have you ever:
No
Yes
Briefly Explain:
Had broken bones?
☐
☐
Been hospitalized?
☐
☐
Been in an auto accident?
☐
☐
Had sprains / strains?
☐
☐
Been struck unconscious?
☐
☐
Had surgery?
☐
☐
Had head injury or trauma?
☐
☐
Received any vaccinations?
☐ ☐
HABITS
NONE
LIGHT
MODERATE
HEAVY
ALCOHOL
☐
☐
☐
☐
COFFEE
☐
☐
☐
☐
TOBACCO
☐
☐
☐
☐
DRUGS
☐
☐
☐
☐
EXERCISE
☐
☐
☐
☐
SLEEP
☐
☐
☐
☐
APPETITE
☐
☐
☐
☐
SOFT DRINKS
☐
☐
☐
☐
WATER
☐
☐
☐
☐
SALTY FOODS
☐
☐
☐
☐
SUGARY FOODS
☐
☐
☐
☐
ARTIFICIAL SWEETENERS
☐
☐
☐
☐
SIGNATURES
PATIENT NAME (PRINTED):
I understand that the Office of Dr. Kate Keville does not file insurance claims. I understand and agree that health/accident
insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services
rendered to me and charged are my personal responsibility and are due at time of service.
PATIENT’S SIGNATURE:
DATE:
SPOUSE OR GUARDIAN SIGNATURE:
DATE:
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Have you ever suffered from any of the following?
☐ Alcoholism
☐ Allergies
☐ Anemia
☐ Arteriosclerosis
☐ Arthritis
☐ Asthma
☐ Back Pain
☐ Breast Lump
☐ Bronchitis
☐ Bruise Easily
☐ Cancer
☐ Chest Pain/Conditions
☐ Cold Extremities
☐ Concussion
☐ Constipation
☐ Cramps
☐ Depression
☐ Diabetes
☐ Digestion Problems
☐ Dizziness
☐ Ears Ring
☐ Excessive Menstruation
☐ Eye Pain or Difficulties
☐ Fatigue
☐ Frequent Urination
☐ Headache
☐ Hemorrhoids
☐ High Blood Pressure
☐ Hot Flashes
☐ Irregular Heart Beat
☐ Irregular Cycle
☐ Kidney Infection
☐ Kidney Stones
☐ Loss of memory
☐ Loss of balance
☐ Loss of smell
☐ Loss of taste
☐ Lumps in Breast
☐ Neck Pain or Stiffness
☐ Nervousness
☐ Nosebleeds
☐ Pacemaker
☐ Polio
☐ Poor Posture
☐ Prostate Trouble
☐ Sciatica
☐ Shortness of breath
☐ Sinus Infection
☐ Sleep problems or
Insomnia
☐ Spinal Curvatures
☐ Stroke
☐ Swelling of ankles
☐ Swollen Joints
☐ Thyroid Condition
☐ Tuberculosis
☐ Ulcers
☐ Varicose Veins
☐ Venereal Disease
☐ Other
Please use the following letters to indicate TYPE and
LOCATION of the symptoms you currently are
experiencing.
A=
Acne O = Other
B=Burning P=Pins & Needles
N=Numbness S=Stabbing
© Copyright 2005 ChiroMatrix
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NEW PATIENT HEALTH HISTORY FORM (Dr. Kate Keville)

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Completed 13 October 2021

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