Health History Form
Olson Family Chiropractic
17502 Dodd Blvd.
Lakeville, MN 55044
Patient Information
First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Home Phone:
Date of Birth:
Age:
Cell Phone:
Email:
☐ Married
☐ Single
☐ Widowed
☐ Divorced
# of Children:
Employer:
Occupation:
How did you hear about our office?
Presenting Concerns
What problem(s) brought you here today?
Example: Headache, Ankle, Vertigo
What caused this condition?
When did this condition start?
Worse in morning or evening?
How often does it occur?
☐ 0-25% of day
☐ 26-50% of day
☐ 51-75% of day
☐ 76-100% of day
Does this pain travel to any other area?
What makes the problem better?
What makes it worse?
What else have you done to treat the problem?
Have you seen any other healthcare provider for
this condition? If so, indicate name of facility:
What was the Diagnosis?
1
Circle the area where you have a complaint on the drawing below.
Draw an arrow with descriptive words below that best describes your condition.
Dull
headache
Sharp
pain
Dull
Sharp
Throbbing
Burning
Deep
Aching
Tingling
Stabbing
Cramping
Numbness
Radiating
Stiffness
Pain Scale
Please circle the number that best describes your pain
0 is no pain, and 10 is the worst pain you’ve ever experienced
List Complaint 1 here: _________________________________
0
1
2
3
4
5
6
7
8
9
10
List Complaint 2 here: _________________________________
0
1
2
3
4
5
6
7
8
9
10
List Complaint 3 here: _________________________________
0
1
2
3
4
5
6
7
8
9
10
Work & Lifestyle
Please check the following daily activities made more difficult from your condition(s)
☐ Sitting
☐ Standing
☐ Walking
☐ Bending
☐ Stooping
☐ Lifting
☐ Sleeping
☐ Sneezing
☐ Coughing
☐ Straining
☐ Reaching
☐ Twisting
☐ Looking up
☐ Looking down
☐ Movement
☐ Rest
☐ Lying face up
☐ Driving
☐ Typing
☐ Scooping
☐ House chores
☐ Exercise
☐ Lying down
☐ Stair Stepping
☐☐
Please select the statement that best describes your current health objectives:
I want the doctor to decide what is best for my condition.
Relief Care- (I only want relief. I am not interest in improving my health or correcting the cause).
☐ Correction- (I want to correct the causes of my health concerns and rebuild strength and stability).
☐ Health/Wellness- (I am interested in improving and maintaining my health, vitality, and lifestyle).
Social History
Alcohol:
Homemade food:
Soft Drinks:
Water:
☐Daily
☐Daily
☐Daily
☐Daily
☐Weekly
☐Weekly
☐Weekly
☐Weekly
☐Occasional
☐Occasional
☐Occasional
☐Occasional
☐Never
☐Never
☐Never
☐Never
Other: _______________
Other: _______________
Other: _______________
Other: _______________
Caffeine:
Exercise:
Tobacco:
☐Daily
☐Daily
☐Daily
☐Weekly
☐Weekly
☐Weekly
☐Occasional
☐Occasional
☐Occasional
☐Never
☐Never
☐Never
Other: _______________
Other: _______________
Other: _______________
2
Medications & Supplements
Please list all current medications (including over the counter meds) and vitamins, minerals and supplements.
Medications
Vitamins/Minerals/Supplements
Past Health History
Please check if you have experienced any of the health issues in the last year.
☐Low Back Pain
☐Middle Back Pain
☐Neck Pain
☐Hip/Leg Pain
☐Joint Pain
☐Shoulder/Arm Pain
☐Headaches
☐Nausea
☐Sleep Disorders
☐Memory Loss
☐Polio
☐Thyroid Conditions
☐Depression
☐Alcoholism
☐Diabetes
☐Tuberculosis
☐Weak Muscles
☐Nervousness
☐Throat/Voice
☐Numbness
☐Dizziness
☐Seizures
☐Shaking/Tremors
☐Cramps
☐Loss of Balance
☐Loss of Smell
☐Loss of Taste
☐Sinus Infection
☐Allergies
☐Asthma
☐Wheezing
☐Shortness of Breath
☐Excessive Thirst
☐Genital Pain
☐Heartburn
☐Eyes/Vision
☐Ears/Hearing
☐Sinus Pain/Drainage
☐High Blood Pressure
☐Varicose Veins
☐Cold Hands/Feet
☐Kidney stones
☐Frequent urination
☐Prostate trouble
☐Fatigue
☐Swollen Joints
☐Arthritis
☐Venereal Disease
☐Poor Circulation
☐Chest Pain
☐Lungs/Breathing
☐Dental/TMJ clicking
☐Anemia
☐Diarrhea
☐Constipation
☐Stroke
☐Arteriosclerosis
☐Irregular heart beat
☐Pacemaker
☐Ulcers
☐Bruise Easily
☐Hemorrhoids
☐Cancer
Female Only
☐Menstrual Problems
☐Back Pain with Period
☐Birth Control
Is there any possibility you are pregnant?
☐Breast Lumps
☐Breast Implants
☐Breast Pain
☐Yes ☐No
Surgeries/Injuries
List Area of Injury & Date(s)
●Have you ever had any major
injuries? If Yes, include date(s)
●Have you ever been in a
serious automobile accident?
●Have you had any previous
surgeries?
●Have you had any joint injuries
or broken bones?
●Have you ever had any
Hospitalizations?
☐Yes ☐No
☐Yes ☐No
☐Yes ☐No
☐Yes ☐No
☐Yes ☐No
3
Family Health History
☐☐☐☐☐☐
Is there a family history of the following, if so, list relation below:
Cancer
Diabetes
Heart or Stroke
Lung
Obesity
Other: __________________________
☐ ☐ ☐ ☐
☐ ☐ ☐ ☐
Does anyone in your family experience the following, if so, list relation below:
Earaches:
Asthma:
Bed Wetting:
Colic:
IBS, Crohn’s, Colitis:
Erectile Dysfunction:
Fertility Issues:
Vertigo
General Health
☐Yes
☐Yes
☐Yes
☐Yes
Have you missed work in the past year due to a health issue?
Do you experience a cold or the flu more than once a year?
Do you regularly use medications for pain?
Do you take vitamins regularly?
How well do you deal with stress?
How is your diet?
How are your energy levels?
What is your attitude towards life?
How restfully do you sleep?
How many hours of sleep / night?
☐Excellent
☐Excellent
☐Excellent
☐Excellent
☐Excellent
☐0-4 hours
☐Good
☐Good
☐Good
☐Good
☐Good
☐5-8 hours
☐Poor
☐Poor
☐Poor
☐Poor
☐Poor
☐More than 8
☐No
☐No
☐No
☐No
☐Unsure
☐Unsure
☐Unsure
☐Unsure
☐Unsure
Recreation History
Activities including
Frequency & Duration:
In general, how would you rate your current overall health & vitality?
(Not Well)
1
2
3
4
5
6
7
8
9
10 (excellent)
*I understand that my care in this office involves the making of judgments that are based upon the facts known by the
doctor. Therefore, the above information is true and complete to the best of my knowledge. I hereby assign all
insurance benefits applicable payable for my care to this office. I understand that I am financially responsible for
charges not covered by this assignment and all charges the insurance carrier or my policy does not cover. I hereby
authorize the release of all HIPAA protected health information to my insurance carrier or to any party who may
become liable for my care.
X
Patient’s Signature
or Parent if under 18 years of age
Date
4