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  • Initial Patient History Checklist

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    info7588
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    This document appears to be a checklist from a chiropractic office for a new patient to check off any health conditions they experience. The checklist includes common symptoms and conditions related to the digestive system, lungs, ears, emotions, eyes, head, mouth/throat, nose, skin, joints/muscles, and other general conditions such as frequent illness, urination issues, and various disorders. The patient is asked to check off any items that apply to help assess their overall health concerns.

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    This document appears to be a checklist from a chiropractic office for a new patient to check off any health conditions they experience. The checklist includes common symptoms and conditions related to the digestive system, lungs, ears, emotions, eyes, head, mouth/throat, nose, skin, joints/muscles, and other general conditions such as frequent illness, urination issues, and various disorders. The patient is asked to check off any items that apply to help assess their overall health concerns.

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    Attribution Non-Commercial (BY-NC)
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    19 views1 page

    Initial Patient History Checklist

    Uploaded by

    info7588
    This document appears to be a checklist from a chiropractic office for a new patient to check off any health conditions they experience. The checklist includes common symptoms and conditions related to the digestive system, lungs, ears, emotions, eyes, head, mouth/throat, nose, skin, joints/muscles, and other general conditions such as frequent illness, urination issues, and various disorders. The patient is asked to check off any items that apply to help assess their overall health concerns.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
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    of 1

    Gibson Chiropractic, P.A.

    93 West Colt Square, Suite 3


    Fayetteville, AR 72703

    Tele (479) 587-0227 Fax (479) 587-0227

    BioVedaWellness.com

    PLEASE CHECK OFF THE FOLLOWING THAT APPLY TO YOU:

    Digestive Track __swollen/tender joints Weight


    __nausea & vomiting __growing pains in legs __binge eating/drinking
    __diarrhea __Psoriatic/Gouty Arthritis S __craving certain foods
    __constipation __Rheumatoid Arthritis S __excessive weight
    __bloated feeling __compulsive eating
    __stomach pains or cramps Lungs __water retention
    __heart burn __chest congestion
    __blood and/or mucous in __bronchitis
    stools __shortness of breath
    __difficulty breathing General
    Ears __persistent cough __frequent illness
    __itchy ears __wheezing __frequent/urgent urination
    __ear aches/ear infections __genital itch/discharge
    __drainage from ear Mind __anal itching
    __ringing in ears __poor memory
    __hearing loss __difficulty completing projects Genitourinary
    __reddening of ears __difficulty with mathematics __kidney problems
    __underachiever __urinary tract
    Emotions __poor/short attention span __bladder
    __mood swings __confusion __yeast infections
    __anxiety/fear/nervousness __easily distracted
    __anger/irritability/aggressiven __difficulty making decisions Other Conditions
    ess __mild learning Disabilities __Autism S
    __argumentative __A.D.H.D. S
    __frustrated/cries easily Mouth & Throat Thrush __A.D.D. S
    __Depression S __chronic coughing __Psoriasis S
    __gagging/clearing throat __Eczema S
    Eyes often __Auto Immune Disorder S
    __watery or itchy eyes __sore throat/hoarse __Chronic Fatigue S
    __red/swollen/itchy eyelids voice/voice loss __Multiple Chemical
    __bags or dark circles under __swollen/discolored Sensitivities S
    eyes tongue/lips __Asthma S
    __blurred or tunnel vision __canker sores __Congestive Heart Failure S
    __itching on roof of mouth __Severe Diabetic S
    Head __Severe Depression S
    __headaches Nose __Obsessive Compulsive
    __faintness __stuffy nose Disorder
    __dizziness __chronically red/inflamed
    __insomnia/sleep disorder nose
    __facial flushing __sinus problems
    __Irregular/Skipped Heartbeat __hay fever
    S __sneezing attacks
    __Rapid/Pounding Heartbeat S __excessive mucous formation
    __Chest Pain S
    Skin
    Joints & Muscles __acne
    __pains/aches in joints __itching
    __arthritis/osteoarthritis __hives/rash/dry skin
    __stiffness/limited movement __hair loss
    __pain/aches in muscles __flushing/hot flashes
    __feeling weak/tired

    Date

    Patient Name

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