Patient Name:_____________________________________________________________ Date:_______________
• ONSET: of chief complaint + location - Insidious? - Traumatic?
• PROVOCATION: what makes it worse?
• PALLIATIVE: what makes it better? Self treatment?
• PERSISTENCE: how long do these complaints last?
• PROGRESSION: are the complaints gotten Better-Worse-Same?
• PRIOR: have you had similar complaints before?
• QUALITY: of Pain
• RADIATION: does the pain "move" or Radiate?
• RESTRICTIONS: does the pain stop you from doing any of your normal activities?
• SEVERITY: scale 1-10, 10 being the most severe.
• SEQUELA: have you had any conditions in the past that have left you with ongoing problems?
• TIMING: Worse in the Morning - Night - No Change?
• AUTO ACCIDENTS: Dates, Car Towed? Totaled? Paramedics? Direction of impact- hit your head?
• OTHER MAJOR TRAUMAS: Concussions?
• MEDICATIONS: for what purpose:
• ALLERGIES: to what –FOOD – MEDICATIONS - SEASONAL - reaction?
• SURGERIES: any complications?
• HOSPITALIZATIONS: What for?
**personal and family history**
• BLOOD SUGAR/ DIABETES: yourself or family member?
• CANCER: yourself or family member?
• STROKE: yourself or family member?
• DOCTORS: Being seen?
• X-RAYS: when and of what part of your body? Were you STANDING? for the X-Ray?
• SOCIAL HISTORY Tobacco – Alcohol - Stress Level- Quality of Sleep
Exercise Coffee, Tea, Sodas, servings of: Fruits & Vegetables; Water Intake - Head Aches?
Weight Goals: Loss / Gain?
HOW DOES THIS EFFECT YOUR : WORK ?
? Patient's Expectations From Chiropractic Treatment:
DrBackman.com Chiropractic 2012©