Fitzgibbon Family Chiropractic

Fitzgibbon Family Chiropractic

Dr. James D. Fitzgibbon

Personal Health History

Name:______Soc. Sec.#: ______- __ __-______

Address:______City______State_____ Zip_____

Home # ( )______Cell# ( )______Preference? H C

Date of Birth: ______/______/______Age:______Marital Status: S M D W

Spouse's Name: ______Number of children in family: ______

Name:______Age:______Name:______Age:______

Name:______Age:______Name:______Age:______

Name of Employer:______Occupation:______

Address of Employer:______

Who may we thank for referring you?______

Name of Previous Chiropractor: ______Date of Last Visit:______

For how long were you receiving chiropractic care?______How often did you go? ______

If you stopped, why did you discontinue care?______

Does your immediate family receive chiropractic care?______

Reason for coming in?______How long have you had this condition?______

Does this effect your work? Yes No

Is this condition: Work Related?______Due to a care accident? ______

What aggravates this condition? ______

What helps your symptoms? ______

Other doctors seen for this condition? ______

Hobbies/ Physical Activities

What hobbies do you participate in?______

What type of physical activities do you participate in? ______

Do you exercise regularly? Yes No If yes, how many hours per week?______

Surgery

What major surgery have you had? (include dates) ______

What minor surgery have you had? (include dates) ex. Tonsillectomy, appendectomy, wart, cyst removal, dental extraction, etc. ______

Medication

Present Prescription Drugs Past Prescription Drugs Over the Counter Drugs

______

______

Current Health

How would you describe your current health? ______

How would you describe your family's health? ______

Describe your: Hearing ______Vision ______Coordination ______

Do you use any of the following: Tobacco Alcohol Coffee/Tea Cola Milk

Rate the level of stress in your life: Mild Moderate Extreme

Do you purchase any of the following: Bottled Water Vitamins Health Food Products

Please check any of the following that give you difficulty or you have had recently:

___Headaches___Fainting___Shortness of Breath

___Sinus Trouble___Loss of Smell___Allergies

___Asthma___Thyroid Trouble___Fatigue

___Depression___Dizziness___Earache

___Neck Pain___Heart Trouble___Stomach Trouble

___Nervousness___Irritability___Low Back Pain

___Arthritis___Lung/Bronchial___Sleeping Problems

___Painful Joints___Hip Pain___Ulcers

___TMJ___Rib/Chest Pain___Bowel Problems

___Kidney/Bladder___Palpitations___Circulatory

___Numbness___Diabetes/Hypoglycemia

______/______/______

Signature of Patient DATE

LAST UPDATED 10/20/2014