Patient Information .pdf

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Patient Name: ___________________________________
DOB: __________________________________________

Acct#____________________________________
Claim#___________________________________

PATIENT INFORMATION

Name__________________________________________________________________________
DOB______________Age______ Sex M____ F____ SS# * ___________________________
Address________________________________________________________________________
City_________________________________ State__________________ Zip_________________
Home Phone_____________________________ Work Phone_____________________________
Cell Ph_________________________________ E-mail__________________________________
Marital Status: M___ S___ D___ W___ Sep___ Spouse / Partner___________________________
You Primary Care Provider_________________________________________________________
Your Employer ____________________________________ Job/Title_______________________
Whom may we thank for referring you? _______________________________________________
Referring Doctor (if any) ___________________________________________________________
*Per HIPAA regulations, and our strict office policy, none of your private information, including your SS# is ever released or
shared with anyone without your written permission. Your SS# is used only to verify your identity and confirm your insurance
benefits.
A complete Oregon Board of Chiropractic Examiners “Patient’s Bill of Rights” is available upon request.

Your Visit Today
Is your visit related to an injury?

Yes______ Date of Injury ________________
No ______ Please give date of first symptoms____________________
Was injury from: Auto Accident____ Work____ Home____ Sports injury____ Fall____ Airplane_____
Other Injury_________________________________________________________________________________
Please describe how you were injured or other pertinent information______________________________________
____________________________________________________________________________________________
Have you had the same or similar injury or symptoms before? Yes______ Date of injury__________ NO______
Date you reported the injury / accident to your insurance company_______________ Employer________________

Prior Treatment for this Condition
List dates for >>
Chiropractic
Massage
Acupuncture
Physical
Therapy
Medical

Current

Previous

X- Both

For What:

By Whom:

Total Family Chiropractic, PC D. Scott Conklin, DC 4309 SE Woodstock Blvd #120 Portland, OR 9720 503-777-4221

Page 1 of 3

Patient Name: ___________________________________
DOB: __________________________________________

Acct#____________________________________
Claim#___________________________________

Patient Information continued…

Social History
Please indicate your personal habits as indicated. (All information is confidential)
Hours of sleep at night: _______ Sleep issues:_____________________________________________________
Do you smoke: cigarettes / cigars / pipe Yes_____ No_____ if yes PPD?________
In the past? Years?______PPD?________
Drink Alcohol: Yes_____ No_____ if yes, what, how much & how often________________________________
Exercise Yes______ No______ if yes, how often___________________________________________________
Medications/ vitamins / minerals /herb supplements:__________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Past Medical History
Allergies / Asthma (including food allergies)
____________________________________________________________________________________________
____________________________________________________________________________________________
Please list any operations / surgeries that you have had, including date(s):
____________________________________________________________________________________________
____________________________________________________________________________________________
Please list any major diseases, illnesses or hospitalizations you have had, including date(s) & reason(s):
____________________________________________________________________________________________
____________________________________________________________________________________________
Please list any fractures / broken bones, or major injuries you have had including date(s):
____________________________________________________________________________________________
____________________________________________________________________________________________

Family History
If there is a family history of any of the conditions listed below, please indicate: (M) Mother; (F) Father; (B) Brother;
(S) Sister; (R) other Relative

_____Diabetes
_____Heart Disease
_____Spinal Problems _____Liver Disease
_____Osteoporosis
_____Thyroid

_____Stroke
_____Cancer
_____Psychiatric

_____Circulatory Problems
_____Bowel Disease
_____Kidney Disease/stones

Other_______________________________________________________________________________________________
^If you have been in a CAR ACCIDENT or INJURED AT WORK, please let the front desk know IMMEDIATELY, as there
are specific forms necessary for automobile accidents and work injuries due to insurance liability issues. Thank you.

Total Family Chiropractic, PC D. Scott Conklin, DC 4309 SE Woodstock Blvd #120 Portland, OR 97206 503-777-4221

Page 2 of 3

Patient Name: ___________________________________
DOB: __________________________________________

Acct#____________________________________
Claim#___________________________________

Patient Information continued…

Your Main Complaint(s) and Pain Intensity
Please check the symptoms that you are having, using (C) for current, (P) for past, or (CP) if both apply.
_____Headaches
_____Rib pain
_____Dizziness/loss of balance
_____TMJ
_____Chest pain
_____Fainting
_____Neck pain or stiffness
_____Hip pain
_____Ringing in ears
_____Sinus problems
_____Low back pain or stiffness
_____Change in smell/taste
_____Shoulder pain
_____Leg/knee/foot pain
_____Depression/anxiety
_____Arm/hand pain
_____Weakness in legs
_____Shortness/difficulty breathing
_____Grip/hand weakness
_____Numbness/tingling/
_____Difficulty Sleeping
_____Mid-back pain
pins & needles in legs/feet
_____Difficulty urinating
_____Numbness/tingling/
_____Visual Changes
_____Constipation/diarrhea
pins &needles in arms/hands
_____Light Sensitivity
_____Indigestion/heartburn
_____Cold hands/feet
_____Pain behind eyes
_____Menstrual problems
Other complaints_____________________________________________________________________________________
Did the symptoms start: ____Gradually ____Suddenly ____Comes & Goes ____ Constant ____ Intermittent
What makes your pain worse?_______________________________________________________________________
What makes your pain better?________________________________________________________________________
Does your pain radiate, and if so, from where to where? ___________________________________________________
________________________________________________________________________________________________
Please rate your level of pain from 0-10 and describe quality of pain, ie: aches, throbs, stabs, burns, sharp, dull, etc.
Neck________________________________________
Low back_____________________________________

Mid-back_______________________________________
Other__________________________________________

Work and Disability
Are you currently able to work? Yes______ No ______ If no, what dates were you out of work?
From___________ To____________
Were you unable to work as a result of prior injury or symptoms? Yes___________ No___________
If no, From ____________ To ____________
Please list any work or daily activity restrictions that have been placed on you by a doctor or that you have placed on
yourself______________________________________________________________________________________________
___________________________________________________________________________________________
I understand that in order for Dr. Conklin to best asses my condition, contraindications to care, and make appropriate
recommendations, he must obtain a health history and complete information about my past and present health,
including any conditions or symptoms not listed on this form. I agree the above information provided is complete
and accurate to the best of my knowledge and I will notify Dr. Conklin of any new conditions or symptoms. I further
consent to Dr. Conklin examining and evaluating me, or my child, for treatment.
________________________________________________________
Patient signature
________________________________________________________
Parent / Guardian (for minor)

Date_____________________________
Date______________________________

Total Family Chiropractic, PC D. Scott Conklin, DC 4309 SE Woodstock Blvd #120 Portland, OR 97206 503-777-4221

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