Fillable Patient Information Health Questionnaire (Palmer)

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Patient Information Health Questionnaire (Palmer)

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San Jose Clinic File # ________

Date: ___/___/___

90 E. Tasman Dr. Health Questionnaire

San Jose, CA 95134 1-408-944-6100 02/07/12

Health Questionnaire

Patient Information

Patient Title: (check one)  Mr.  Mrs.  Ms.  Miss  Dr.  Prof.  Rev.

First Name Nickname

Last Name Middle Name Suffix

Address 1

Address 2

City State Zip Code

Primary Phone Secondary Phone

Mobile Phone _______________________________

Home email Work Email

By providing my email address, I authorize my doctor to contact me via the email address(es) provided.

Which email address would you like us to use to communicate with you? (check one)  Home  Work

Contact Method

(check one)

 Primary Phone  Secondary Phone  Mobile Phone  Home Email  Work Email

Date of Birth Age Gender

(check one)  Male  Female  Unspecified

Marital Status (check one)  Single  Married  Other

Employment Status

(check one)

 Employed  FT Student  PT Student  Other  Retired  Self Employed

Race (check one)

 White  Black/African American  Hispanic  American Indian/Alaskan Native

 Asian  Asian Indian  Chinese  Filipino

 Japanese  Korean  Vietnamese  Native Hawaiian or other Pacific Island

Samoan  Guamanian or Chamorro Other  I choose not to specify

Multi-Racial (check one) Yes No  Unknown

Ethnicity

(check one)  Hispanic or Latino  Not Hispanic or Latino  I choose not to specify

Preferred Language

(check one)

 English  Spanish  American Sign Language  Chinese  French  German

 Tagalog  Vietnamese  Italian  Korean  Russian  Polish

 Arabic  Portuguese  Japanese  French Creole  Greek  Hindi

 Persian  Urdu  Gujarati  Armenian  I choose not to specify

Verification Question

(choose only one question by circling the question, then give the answer to that question)

 What is the name of your favorite pet?  In what city were you born?  What high school did you attend?

 What is your favorite movie?  What is your mother’s maiden name?  On what street did you grow up?

 What was the make of your first car?  When is your anniversary?

Verification Answer to the Chosen question:

Answers must be at least 6 characters.

/ /

San Jose Clinic File # ________

Date: ___/___/___

90 E. Tasman Dr. Health Questionnaire

San Jose, CA 95134 1-408-944-6100 02/07/12

How Did You Hear About Us?

___A current intern. Please list the name of intern ________________________________________________________

___A current student. Please list the name of the current student ____________________________________________

___A patient. Please list the patient so that we are able to properly thank the person_____________________________

___A faculty member of Palmer West _________________________________________________________________

___A staff member of Palmer West __________________________________________________________________

___Yellow Pages [ ] Phone Book [ ] YP Online

___Internet. [ ] Google search [ ] Other, please specify:_____________________________________________

___Drove by Palmer Campus.

___Advertisement. Please specify._____________________________________________________________________

___Sporting Event. Please specify._____________________________________________________________________

___I am a prospective student visiting the campus today.

___Facebook or other social media.

___Walk-in.

___VTA Light Rail.

___Palmer Alumni. Please specify._____________________________________________________________________

___Other. Please specify_____________________________________________________________________________

Smoking History

Do you currently smoke tobacco of any kind?

 Yes  Former smoker  Never been a smoker

If yes, how often do you smoke:

 Current every day smoker

 Current sometimes smoker

If yes, what is your level of interest in quitting smoking?

 0  1  2  3  4  5  6  7  8  9  10

No interest Very Interested

Allergies

Are you allergic to any medication(s)?

 Yes  No If yes, which medications?

____________________________________

Are you allergic to any of the following?

 Bee Sting

 Latex  Peanuts  Shellfish

 Dairy

 Mold  Pollen  Wheat

 Eggs

 Nuts  Other____________

Describe the reaction

:___________________

Medications

Current medications, including frequency and dosage if known. If there are no current medications, check here:



Medication Name

Quantity / Dosage

(ie.

1 tablet / 5 mg)

Frequency

(ie. 2 times / day)

Start Date

Do you currently use any recreational drugs?  Yes  No [ ] Check here if you take more than 6 medications

San Jose Clinic File # ________

Date: ___/___/___

90 E. Tasman Dr. Health Questionnaire

San Jose, CA 95134 1-408-944-6100 02/07/12

Social History

WORK ACTIVITY: What is your job description: ___________________________________

What do you do most of the day at work?  Sitting  Standing  Light Labor  Heavy Labor  Other:________

What job did you do during most of your life?

How would you describe the physical stress level at work?  Low  Medium  High

EDUCATION : Mark the highest level of education completed:  Elementary school  Middle school  High School

 Vocational School  GED  Associates Degree  Bachelors Degree  Graduate Degree  Doctorate  other

DIET/NUTRITION:

Are you on any special diet?  Yes  No If yes, for what reason?_________________________

Is your weight a concern for you emotionally or physically?  Yes  No

Have you gained or lost over 10 pounds in the past 6 months without wanting to?  Yes  No

My dietary intake consists mainly of the following: (Mark all that apply)

 Fruits  Vegetables  Whole Grains  High Fiber  Low Fiber

 High Salt  Low Salt  High Sugar  Low Sugar  Low Carbohydrate

 High Fat  Low Saturated Fats  High Protein  Low Calorie

Rate your appetite on the below scale of 1 to 10:

Normal Appetite 1 2 3 4 5 6 7 8 9 10 Eat Nothing

How many 8 ounce glasses of water do you drink a day? _____

Alcohol Use: Now?  Yes  No Amount/Weekly____ How long? _____ Years/Months

In the past?  Yes  No Amount/Weekly____ How long? _____ Years/Months

How many coffee caffeine drinks do you drink a day? Cups ____ None ____

How many soda caffeine drinks do you drink a day? Cans ____ None ____

Current Vitamins, Minerals, Herbs, etc. List ANY/ALL non-prescription items you are CURRENTLY taking.

Vitamin, Mineral, Herbs

Quantity / Dosage

(ie.

1 tablet / 5 mg)

Frequency

(ie. 2 times / day)

Start Date

Health Review:

How many hours of sleep are you getting per night?  Less than 5  6-8  8-10  10 or more hours

How would you rate your sleep on the following scale?

Wake-up Fully Rested 0 1 2 3 4 5 6 7 8 9 10 No/Poor Sleep

How many days a week do you exercise for 30 minutes or more?  0  1-2  3-4  5-6  7

How would you rate the intensity of your exercise?

High Intensity 0 1 2 3 4 5 6 7 8 9 10 No Exercise

How would you rate your physical stress level? No stress 0 1 2 3 4 5 6 7 8 9 10 Very stressed

How would you rate your emotional stress level? No stress 0 1 2 3 4 5 6 7 8 9 10 Very stressed

List your major stressors: __________________________________________________________________________

What are you health goals? _________________________________________________________________________

In addition, talk to your doctor about other areas which may be affecting your health-such as worries about finances,

social support, and alcohol, tobacco and/or drug use.

San Jose Clinic File # ________

Date: ___/___/___

90 E. Tasman Dr. Health Questionnaire

San Jose, CA 95134 1-408-944-6100 02/07/12

Personal Health History

Are your currently under the care of a Healthcare Provider or any other doctor?



Yes



If yes, for what condition(s)_________________________________________________________________________

_________________________________________________________________________________________________

Provider’s Name ________________________________________ Phone Number_______________________________

Has any doctor diagnosed you with Hypertension recently?  Yes  No

If yes, describe: _________________________________________________________________________________

Has any doctor diagnosed you with Diabetes recently?  Yes  No

If yes, was your blood lab-work test for hemoglobin A1c >9.0%  Yes  No  Not Sure

If yes, other comments regarding Diabetes: ___________________________________________________________

Have you had an X-ray or CT scan or MRI of your low back spine in the past 28 days?



Yes



Do you wear any of the following?  Heel Lifts  Innersoles  Arch Supports  Orthotics  Other____________

For how long? ________________________________________ Were they prescribed by a doctor?  Yes  No

Have you seen a chiropractor in the past?  Yes  No Date of last visit______________

If yes, name and location of previous Chiropractor___________________________ Phone Number_________________

Were you satisfied with your care?  Yes  No Why? ________________________________________________

Date of last:

Chiropractic Exam

Prostate/PSA

Cholesterol

Mammogram

MRI

Pap Smear

CT-Scan

Colon

Spinal X-ray

Stool check for blood

Childhood Illnesses:

 ADD  depression  psoriasis

 atopic dermatitis  diabetes  rash

 allergies/hayfever  ear infections  scoliosis

 anemia  fetal drug exposure  seizures

 asthma  headaches 

sickle cell

 bedwetting  hepatitis 

spina bifida

 cerebral palsy  HIV  other:

 chicken pox  measles

 crohn’s/colitis  mumps

Immunization:

 All recommended vaccines  Not vaccinated

 adenovirus DTaP(diphtheria,tetanus,pertussis)

 haemophilus B  hepatitis B

 influenza  IPV(polio)

 MMR(

measles,mumps, rubella)

 pneumococcal  rotavirus

 tetanus  varivax(

chicken pox)



other:_________

Adult Illnesses:

 ADD CVA(stroke)  heart disease  Parkinson Disease  suicide

 Alzheimer’s  chicken pox  hepatitis  unspecified pleural effusion attempt(s)

 arthritis  cystic kidney disease  HIV  pneumonia  thyroid

 asthma  depression  high blood pressure  psoriasis problems

 cancer  diabetes  influenza pneumonia  psychiatric condition  vertigo

 cerebral palsy

 eczema  liver disease  scoliosis  Other:______

 chicken pox  emphysema  lung disease  seizures ___________

 colitis  eye problems  lupus erythema  shingles

 CRPS(RSD)  fibromyalgia  multiple sclerosis  STD’s (unspecified)

Injuries: (List date next to injury)

 back injury  fracture  laceration (severe)

 broken bones  head injury  motor vehicle accident

 disability (ies)  industrial accident  soft tissue injury

 fall (severe)  joint injury  Other:______________

San Jose Clinic File # ________

Date: ___/___/___

90 E. Tasman Dr. Health Questionnaire

San Jose, CA 95134 1-408-944-6100 02/07/12

Surgeries:

Date

Procedure

(e.g. knee repair)

Description

In Patient/Out Patient

Review of Systems

Please indicate if you have any of the following by checking the box.

Constitutional

 None  daytime drowsiness  fever  night sweats

 chills  fatigue  loss of appetite  weight gain / loss

Eyes/Vision



None



cataracts



itching



wears contacts/glasses

 blindness  double vision  photophobia

 blind spots  eye problems  tearing

Ears, Nose &

Throat

 None  fainting  history of head injury  runny nose

 dizziness  frequent sore throats  loss of sense of smell  sinus infection

 ear discharge  headaches  nosebleeds

 ear pain  hearing loss  nasal congestion

Respiration

 None  cough  shortness of breath  wheezing

 asthma  coughing up blood  sputum production

Cardiovascular



None



high blood pressure



paroxysmal nocturnal



varicose veins

 claudication  low blood pressure dyspnea

(leg pain and ache)  orthopnea(difficulty  shortness of breath

 heart problem

breathing lying down) with exertion

 heart murmur  palpitations  ulcers

Gastrointestinal



None



belching



difficulty swallowing



jaundice

 abdominal pain  black/tarry stool  heartburn  ulcers

 abnormal stool  constipation  hemorrhoids  rectal bleeding

(Color/consistency)

 diarrhea  indigestion

Female

 None/Not  birth control  frequent urination  vaginal discharge

Applicable  breast lump/pain  hormone therapy



abnormal vaginal  burning urination  irregular menstruation

Bleeding  cramps  urine retention

I …  am currently pregnant  am NOT currently pregnant

I …

 currently have menses  currently DO NOT have menses

My menses…  are regular  are NOT regular

______age of first menses ______age when menopause began

Date of last menstrual period ____/____/____

If you have been pregnant in the past, please fill in the appropriate information below.

______Number of complicated pregnancies ______Number of uncomplicated pregnancies

______Number of C-sections ______Number of vaginal deliveries

______Number of miscarriages ______Number of terminated pregnancies

Do you have any concerns about your sexual health?

 Yes  No

Are you or have you ever been a victim of domestic or sexual abuse?



Yes



Male

 None/Not  burning urination  frequent urination  prostate problems

Applicable  erectile dysfunction  hesitancy/dribbling  urine retention

Do you have any concerns about your sexual health?

 Yes  No

Are you or have you ever been a victim of domestic or sexual abuse?

 Yes  No

San Jose Clinic File # ________

Date: ___/___/___

90 E. Tasman Dr. Health Questionnaire

San Jose, CA 95134 1-408-944-6100 02/07/12

Endocrine

 None  excessive appetite  goiter  unusual hair growth



cold intolerance  excessive hunger  hair loss  voice changes

 diabetes



excessive thirst



heat intolerance

Skin

 None  change in skin color  history of skin disorders rash



change in nail  hair loss  itching  skin lesions/ulcers

texture  hives  numbness  varicosities

Nervous

System

 None  limb weakness  seizures  stroke

 dizziness  loss of consciousness  sleeps disturbance  unsteadiness of gait/loss

 facial weakness  loss of memory  slurred speech of balance

 headache  numbness  stress

Psychological



None



bi-polar disorder



depression



memory loss

 anxiety  confusion  insomnia  mood change



behavioral

change convulsions  loss or change of appetite

Hematologic

 None



bleeding



blood transfusion



fatigue

 anemia



blood clotting



bruising easily



lymph node swelling

Family History

Relation

Age (now

or at death)

Serious illness/cause of death

Father



alive  deceased



no significant disease



has/had__________________

Paternal grandfather



alive  deceased



no significant disease

 has/had__________________

Paternal grandmother



alive  deceased

 no significant disease

 has/had__________________

Mother



alive  deceased



no significant disease



has/had__________________

Maternal grandfather



alive  deceased



no significant disease

 has/had__________________

Maternal

grandmother



alive  deceased



no significant disease

 has/had__________________

Brother(s)



alive  deceased



no significant disease

 has/had__________________

Sister(s)



alive  deceased



no significant disease

 has/had__________________

Son(s)



alive  deceased

 no significant disease

 has/had__________________

Daughter(s)



alive  deceased



no significant disease



has/had__________________

San Jose Clinic File # ________

Date: ___/___/___

90 E. Tasman Dr. Health Questionnaire

San Jose, CA 95134 1-408-944-6100 02/07/12

Patient Condition

Reason(s) for visit:__________________________________________________________________________

Is this condition due to an accident?

 Yes  No  Auto  Work  Home  Other Date___________

What was the mechanism of accident/injury?_____________________________________________________

When did your symptoms appear?_____________________ Is this condition getting worse?

 Yes  No

How often do you have this problem? __________________ Is it constant or does it come and go?______

Does it interfere with your: 

Work  Sleep  Daily Routine  Recreation

Activities or movements that are difficult / painful to perform:

 Sitting  Standing  Walking  Bending  Lying Down

Circle your pain on the below scale of 0 to 10:

(at rest)  No Pain 0 1 2 3 4 5 6 7 8 9 10  Extreme Pain

(with activity)  No Pain

0 1 2 3 4 5 6 7 8 9 10  Extreme Pain

What treatment have you already received for your condition?



Medications  Surgery  None  Physical Therapy  Chiropractic Care

Name of other doctor(s) who have treated you for this condition__________________________________________

Were you satisfied with the results of your treatment?  Yes  No Explain__________________________

Mark an “X” on the picture where you continue to have pain, numbness or tingling.

While we will work closely with you to resolve your chief complaint, as health professionals we are also concerned about

your overall wellness. On future visits we will discuss issues with you that may impact your overall health.

All the answers I have given are correct to the best of my knowledge, and I agree to continue with my Chiropractic

evaluation at the Palmer Clinics at this time.

Patient Signature Date

Signature of Parent or Legal Guardian Relationship

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Patient Information Health Questionnaire (Palmer)

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Completed 18 August 2020

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