test 20juneadmin2023-06-20T06:39:33+00:00 PATIENT HISTORYFirst(Required) Last(Required) Hand Dominance: Right Left Height Weight Primary Care Physician Who referred you to our clinic? Do you see any other medical specialists (i.e., cardiologist, etc.)? If yes, please list: Pharmacy name and address Date of Injury MM slash DD slash YYYY How did the injury occur? Where did the injury occur? Injury result of: Sports Auto Accident *On the Job If on the job, is it Workers’ Comp? Yes No Signature Injury Location : Right Left Injury Location Where? Shoulder Elbow Hand Hip Knee Foot Arm Wrist Finger Leg Ankle Toe What symptoms are you experiencing? Locking Grinding Catching Weakness Popping Numbness Stiffness Other Other symptoms Pain Level (0-10; 10 being severe pain) Have you ever had Physical Therapy for this issue? Yes No What increases your pain? Have you had Chiropractic Treatment? Yes No Have you had any studies or testing for this injury? X-ray MRI CT EMG/NCV Other Other studies or testing for this injury Place and date of these studies: Medical History(Please include any medical conditions you have been treated for)Medical History Option AIDS/HIV Alcoholism Alzheimer’s Anemia Rheumatoid Arthritis Asthma Blood Clot Leg Blood Clot Lung Stroke Osteogenesis Imperfecta Other Disease(s) Medical History Option Cancer - Breast Cancer - Colon Cancer - Lung Cancer - Prostate COPD Depression Diabetes Drug Abuse Sleep Apnea Medical History Option Gout Heart Attack Hypertension Hepatitis Kidney Disease Osteoarthritis Seizures Ulcers, Bleeding Blood Thinners (Plavix, aspirin, etc.) Other Disease(s) Past Surgies/Dates Family History(If family condition exists, please write “father”, “mother”, or “sibling” after condition)Family History Option AIDS/HIV Anemia Blood Clots Cancer Coronary Artery Disease Rheumatoid Arthritis Family History Option Diabetes Gout Heart Attack Hemophilia Hypertension Other Family History Option Kidney Disease Liver Disease Muscle Disease Osteoporosis Osteoarthritis Other Family History FEMALES ONLYCould you be pregnant? Yes No
