HEALTH PROFILE PAPERWORK

Health Profile Paperwork

Patient Name:

First Name
Last Name

Patient #:

Date

WHAT BROUGHT YOU INTO THE OFFICE

If you have no symptoms or complaints and are here for wellness services.

(please check here)

CURRENT HEALTH CONDITION (why are you here today):

CURRENT HEALTH CONDITION (why are you here today)

When did this condition start?

Has it ever occurred before?

Yes

No

Is the condition:

Auto Related

Work Related

No Injury

Other

Since the problem(s) started, it is

Getting Better

About the Same

Getting Worse

What helps the pain/problem?

Please list other practitioners you have seen for this issue:

Are you currently taking any prescription medications?

Yes

No

Are you wearing any of the following?

Heel Lifts

Innersoles

Arch Supports

Orthotics

Have you had recent blood work?

Yes

No

YOUR HEALTH BELIEFS

What tools have you used to try to reduce stress?

What bad habits do you need to release?

How do you currently support your health?

Below is a list of diseases that may seem unrelated to the purpose of your appointment. However, these questions must be answered carefully as the problems can affect your overall course of care.

REVIEW OF SYSTEMS-Please fill out all of the sections, even if “DENY”.

SOCIAL HISTORY

Amount......

Drugs:

Deny any illegal drug use

Deny use of IV drugs

Have not used drugs since

Have used drugs for

Since

Tobacco:

Deny any tobacco use

Live with a smoker

Quit smoking

PATIENT HEALTH HISTORY

Please fill out carefully as these problems can affect your overall course of care.

Surgeries: I…○ Deny any Surgery (ies) Please list what and when:

Injuries: I…○ Deny any Injury (ies) Please list what and when:

Other (please be specific):

FAMILY HISTORY

Father

Alive

Deceased

No significant disease

Has/Had:

has/had....explain

Mother

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:

Maternal Grandfather

Alive

Deceased

No significant disease

Has/Had:

Maternal Grandmother

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:

Brother (s)

Alive

Deceased

No significant disease

Has/Had:

Sister (s)

Alive

Deceased

No significant disease

Has/Had:

Is there anything else you would like us to know, which we have not covered?

Contact

Phone: (815) 396-5250

Email: [email protected]

Address: 5069 Edgemere Ct

Roscoe, IL 61073

HEALTH PROFILE PAPERWORK

Health Profile Paperwork

YOUR HEALTH BELIEFS

PATIENT HEALTH HISTORY

FAMILY HISTORY

Contact