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eliosphotomedicineott@gmail.com
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CONFIDENTIAL CASE HISTORY
Date:
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Your answers will help us determine how our care can help you. If you need help with this form, please do not hesitate to ask us.
PERSONAL INFORMATION
Name:
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First
Last
Email:
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Date of Birth:
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Date / Month / Year
Address:
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Line 1
Line 2
City
State
Zip Code
Country
How did you hear about our office?
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Doctor's Name:
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I consent to the clinic to communicate electronically with me for the purpose of scheduling appointments, appointment confirmations, clinic updates and newsletters.
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Yes
No
HEALTH INFORMATION
Have you ever received laser therapy before?
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Yes
No
Dr. Name:
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When was your last visit?
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What was the problem?
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Had surgery for the problem?
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Yes
No
Metal implant or part inserted?
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Yes
No
Where?
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When?
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Were x-rays taken?
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Have you ever been to a chiropractor before?
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Yes
No
Dr. Name:
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When was your last visit?
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What was the problem?
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REASON FOR CONSULTING OUR OFFICE
What is your major complaint?
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Is this complaint a result of a motor vehicle accident?
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Yes
No
Is this a Workman's Compensation case?
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Yes
No
How long have you had this condition?
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Have you had this or similar conditions in the past?
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Yes
No
if Yes - when?
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What aggravates your condition?
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What makes it better?
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Is this condition getting progressively worse?
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Yes
No
Is this condition interfering with your Work
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Sleep
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Choose One
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Constant
Comes and goes
Daily Routine
Other
Have you been diagnosed with Cancer?
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Yes
No
If yes, list type:
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Treatment received
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(Please complete both sides)
How long has it been since you really felt well?
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Has there been any medical diagnosis of your complaint?
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Yes
No
if yes list the Dr.'s name and diagnosis:
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List surgical operations and years:
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List prescription drugs, over the counter Drugs, Vitamins and Supplements you are currently taking:
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Age of Mattress:
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Comfortable:
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Yes
No
Do you wear:
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Heel Lifts
Sole Lifts
Inner soles
Arch supports
Orthotics
Have you been in an auto accident:
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Never
Past year
Past 5 years
Over 5 years
Description of accident:
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Have you had any other personal injury or accident:
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None
Past year
Past 5 years
Over 5 years
Date of most recent physical examination:
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Please mark the areas of pain and/or discomfort on the figures below:
Please rate your current level of discomfort: 0 no pain; 10 unbearable
Neck
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1
2
3
4
5
6
7
8
9
10
Mid Back
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1
2
3
4
5
6
7
8
9
10
Low Back
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1
2
3
4
5
6
7
8
9
10
Are you affected by any of?
Please check : O = Occasionally F = Frequently C = Constantly
Asthma
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O
F
C
Low Back pain
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O
F
C
Neck pain
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O
F
C
Allergies
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O
F
C
Earache
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O
F
C
Sore Throat
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O
F
C
Headaches
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O
F
C
Sinus Trouble
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O
F
C
Digestive Upset
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O
F
C
Constipation
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O
F
C
Heartburn
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O
F
C
Migraines
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O
F
C
Dizziness
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O
F
C
High blood pressure
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O
F
C
Females Only:
Painful menstruation
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O
F
C
PMS
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O
F
C
Are you pregnant?
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Yes
No
Patient's Signature:
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Patient consent for examination
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Yes
No
Doctor's Initials
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Date:
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