Patient Form

Worthington Spine and Wellness Center Tel: (866) 673-9721
Dr. Ardie B. Singh, D.C. Fax: (614) 436-2052
55 Caren Avenue, Suite 360


CONFIDENTIAL PATIENT INFORMATION

Personal Information

Full name:
 Date:
Address(Street/City/State/Zip):
Home phone:
 Work phone:
Cell phone:
 Email address:
Best time/place to contact you:
Date of birth:
 Age:
No. of children:
 Pregnant?:
Yes
No
Height:
 Weight:
Social Security Number:
Marital Status:
 Spouse/guardian name:
Occupation:
Employer’s name & address:
Spouse’s Occupation/Employer:
Name of person responsible for account:
Do you have insurance that covers Chiropractic care?:
Yes
No		 Do you have Medicare coverage?:
Yes
No
Name of Insurance Company:
Insurance Policy number:
 Insurance Company phone number:
Insurance Company address:
Who may we thank for referring you? :

Addressing What Brought You Into This Office:

If you have no symptoms or complaints and are here for Chiropractic Wellness Services, please skip to the “General Health History”.

Health Concerns

Please list your health concerns according to their severity Rate of severity
1 = mild
10 = worst imaginable 		When did this episode start? If you had this condition before, when? Did the problem begin with an injury? % of the time pain is present
1.
2.
3.
4.
5.
Is your pain dull? Or is your pain sharp? Does it radiate anywhere? If so, where? :
Since the problem started is it:
About the same?
Getting better?
Getting worse?
What have you done for this condition? Was it of benefit? :
I do (do not) have a family history of this or similar symptoms (Please explain) :
Which activities aggravate your condition? :

Other doctors you have seen for this condition:

“Limited Scope” Chiropractor (focuses mainly on neck and back pain)
“Wellness” Chiropractor (focuses on health and well being as well as underlying cause of pain and health concerns)
Medical Doctor
Dentist
Other (please describe)

Doctor’s details:

Name:
 Address:
When did you see them?
What did they say was wrong?
Did it help?
 What did they do?

Name:
 Address:
When did you see them?
What did they say was wrong?
Did it help?
 What did they do?

Have you been “forced” or “felt the need” to make any “positive” changes in your life due to this pain, illness, condition, etc?
(i.e., eat better, less alcohol or drugs, meditate or breathe more, less destructive sports, activities, etc.) If so, what?

Is this condition interfering with any of the following:

Work
 Sleep
 Daily routine
 Sports/exercise
 Other
(please expain):

General Health History

Often times, accumulation of life’s stress can lead to health problems and influence our ability to heal. Please pay close attention to this as it will help us help you!

Have you had any surgery? (Please include all surgery)

1. Type:
 When?
 Doctor
2. Type:
 When?
 Doctor
3. Type:
 When?
 Doctor

Have you had any accidents and/or injuries: auto, work-related, or other? (Especially those related to your present problems).

1. Type:
 When?
 Hospitalized?
Yes
No
2. Type:
 When?
 Hospitalized?
Yes
No
3. Type:
 When?
 Hospitalized?
Yes
No

Have you ever had x-rays taken?

Area of body:
 When?
 Where?

Do you wear orthotics or heel lifts?

Yes
No

Current Medicines and Supplements

Please list any medications/drugs you have taken in the past 6 months and why: (prescription and non-prescription)

Please list all nutritional supplements, vitamins, homeopathic remedies you presently take and why:

Are you interested in knowing more about how your nutrition (food you eat) affects your overall health and well-being? Yes
No
Maybe
If dietary changes are indicated would you be willing to make changes in your diet? Yes
No
Maybe
Would you take whole food supplements if indicated? Yes
No
Maybe
If specific exercises or stretching would help would you consider adding them to your program? Yes
No
Maybe
If reducing stress would you help you would you like to know ways to reduce stress? Yes
No
Maybe

Diet

Please circle any dietary selection that is appropriate for you, and grade according to the following scale:

D - Consume this daily | FD - Consume this a few times per day | W - Consume this weekly | FW - Consume this a few times per week
FM - Consume a few times per month (less than weekly) | M - Consume this monthly | O - Do not consume this

Alcohol
 Eggs
 Fasting
 Artificial Sweetener
Tobacco
 Fruit
 Diet food
 Weight Control Diet
Coffee
 Beef
 Refined Sugar
 Raw Vegetables
Soda
 Poultry
 Fish
 Whole Grains
Fried Foods
 Organic foods
 Seafood
 Dairy
Cooked or canned vegetables

The type of diet I usually follow is classified as:

Past Health History

Please mark the following conditions you may have had or have now (- have had + have now):

Alcoholism Allergy Anemia Arteriosclerosis Arthritis Asthma
Back Pain Cancer Cold Sores Constipation Convulsions Depression
Diabetes Diarrhea Eczema Emphysema Epilepsy Gall Bladder Problems
Gout Headaches Heart Attack Heart Disease High Blood Pressure HIV (Aids)
Irregular Periods Low Blood Sugar Malaria Measles Menstrual Cramps Migraines
Miscarriage Multiple Sclerosis Mumps Neck Pain Nervousness Neuritis
Pleurisy Pneumonia Polio Rheumatic Fever Ringing in ears Sinus Problems
Stroke Thyroid Problems Tuberculosis Ulcers Venereal Disease Whooping Cough
Other (please explain)

Stressors

Because accumulation of stress affects our health and ability to heal please list your top three stresses (you have ever had) in each category:

  1. Physical stress (falls, accidents, work postures, etc.)

  2. Bio-chemical stress (smoke, unhealthy foods, missed meals, don’t drink enough water, drugs/alcohol, etc.)
  3. Psychological or mental/emotional stress (work, relationships, finances, self-esteem, etc.)

On a scale of 1-10 please grade your present levels of stress (including physical, bio-chemical and psychological or mental/emotional):

At work:
 At home:
 At play:

On a scale of 1-10, (1 being very poor and 10 being excellent) please describe your:

Eating habits:
 Exercise habits:
 Sleep:
 General health:
 Mind set:

How do you grade your physical health?

Excellent
 Good
 Fair:
 Getting better
 Getting worse

How do you grade your emotional/mental health?

Excellent
 Good
 Fair
 Getting better
 Getting worse

Is there anything else which may help to better understand you which has not been discussed?

Why are you here at this point in time?

I consent to a professional and complete chiropractic, neurological, and orthopedic examination that the doctor deems necessary.

Print Patient Name:

Date:

Signature(Enter your name):