Family History. Mother’s age: If deceased, how old were you when she died? Father’s age: If deceased, how old were you when he died? If your parents are separated or divorced, how old were you then? Number of brother(s) Their ages Number of sister(s) Their ages I was child number in a family of children. Were you adopted or raised with parents other than your natural parents? Yes No Briefly describe your relationship with your brothers and/or sisters: Which of the following best describes the family in which you grew up? WARM AND HOSTILE AND ACCEPTING AVERAGE FIGHTING 1 2 3 4 5 6 7 8 9 Which of the following best describes the way in which your family raised you? ALLOWED ME TO BE VERY ATTEMPTED TO YOUR MOTHER (or mother substitute) Briefly describe your mother: _ How did she discipline you? How did she reward you? How much time did she spend with you when you were a child? much average little Your mother’s occupation when you were a child: stayed home worked outside part-time worked outside full-time How did you get along with your mother when you were a child? poorly average well How do you get along with your mother now? poorly average well Did your mother have any problems (e.g., alcoholism, violence, etc.) that may have affected your childhood development? Yes No (If yes, please describe) Is there anything unusual about your relationship with your mother? Yes No (If Yes, please describe) YOUR FATHER (or father substitute) Briefly describe your father: How did he discipline you? How did he reward you? How much time did he spend with you when you were a child? much average little Your father’s occupation when you were a child: stayed home worked outside part-time worked outside full-time How did you get along with your father when you were a child? poorly average well How do you get along with your father now? poorly average well Did your father have any problems (e.g. alcoholism, violence, etc.) that may have affected your childhood development? Yes No (If yes, please describe) Is there anything unusual about your relationship with your father? No Yes (If yes, please describe)
Family History. Pedigree
Family History. Please indicate with an “X” any significant family medical history or problems.
Family History. The Division will determine whether an immediate family member is assigned to a Contractor and assign the Member to that Contractor.
Family History. Please indicate with an “X” any significant family medical history or problems. □ asthma □ tuberculosis □ sleep apnea □ COPD or Emphysema □ other lung : □ heart attack, myocardial infarction □ congestive heart failure □ irregular heartbeat, arrhythmia □ bleeding problems other heart : □ Peripheral neuropathy □ MS or Xxxxxxxxx’x □ other neuro : □ osteoarthritis □ Lupus □ gout □ rheumatoid arthritis □ Other bone & joint: □ acid reflux, GERD □ inflammatory bowel disease hepatitis - Type □ liver disease □ other GI : □ kidney problems □ dialysis, kidney failure □ diabetes □ psoriasis □ high cholesterol or lipids □ thyroid problems □ sickle cell disease □ any skin ulcer □ Malignant hyperthermia Cancer : any type -- please specify Other medical problems NOT included above (explain) Please check any and all insurance coverage you or your spouse has applicable in this case. □ Medicare □ Auto Accident □ Medicaid □ Major Medical □ BC/BS □ Worker’s Compensation □ Other Date of Accident: Insurance Company Name: Adjuster: Address/Phone: Claim #: Policy #: Effective Date: Name & Address (if known): Phone #: Attorney Name & Address: Attorney Phone #: *Person to contact in an emergency (Name and Phone #): l declare under penalty of xxxxxxx (under the laws of the United States of America) that the foregoing is true and correct: I am not attempting to investigate Results Chiropractic, LLC or it’s staff as a representative of any agent or entity (private or governmental), or any insurance company or other organizational entity or person. Signature: Name (printed): Date:
Family History. Tell me about your family (i.e. child's parents, siblings,
Family History. Parents (Any history of inherited disorders eg. asthma, hear problems, learning difficulties etc): Learner concerned ( Any inherited disorders eg. asthma, heart problems, learning difficulties etc): Siblings ( Any inherited disorders eg. asthma, heart problems, learning difficulties etc): Extended family ( Any inherited disorders eg. asthma, heart problems, learning difficulties etc):
Family History. Family History Unknown Heart Disease Alcoholism High Blood Pressure Anemia High Cholesterol Anesthetic Problems Kidney / Bladder Disease Arthritis Lung / Respiratory Disease Asthma Migraines Bleeding Disease Osteoporosis Breast Cancer Seizures / Convulsions Colon / Rectal Cancer Severe Allergy / Hives Depression Stroke / CVA of the Brain Diabetes Thyroid Cataract Surgery Left Right Both Carpal Tunnel Surgery Left Right Both Deviated Nose Septum Left Right Both Rotator Cuff Repair Left Right Both Sinus Surgery Positive History Shoulder Surgery Left Right Both Mastoidectomy Left Right Both Hip Fracture & Surgery Left Right Both Tonsillectomy Left Right Both Hip Replacement Left Right Both Carotid Artery Surgery Left Right Both Knee Surgery Left Right Both Thyroid Removal Left Right Both Neck Surgery Positive History Breast Biopsy Left Right Both Low Back Surgery Positive History Breast Lump Removal Left Right Both Spinal Fusion Positive History Lung Surgery Left Right Both Spinal Decompression Positive History Heart Bypass Surgery Left Right Both Ulcer Surgery Positive History Heart Valve Replacement Left Right Both Appendectomy Positive History If you have had spinal surgery, please indicate date & facility: Gallbladder Surgery Positive History Kidney Removal Left Right Both Inguinal Hernia Surgery Positive History Colon Polyp Removal Positive History Colon Removal Positive History Anal Fissure Repair Positive History Leg Circulation Surgery Left Right Both Foot Surgery Left Right Both Have you had any pain management procedures? YES NO What procedures? Major joint injection Facet Joint Injection Epidural Discectomy Rhizotomy Please indicate date & facility: Did you get any relief from injections/procedures? YES NO If so, how long?
Family History. Please indicate with an “X” any significant family medical history or problems. □ asthma □ tuberculosis □ sleep apnea □ COPD or Emphysema □ other lung : □ heart attack, myocardial infarction □ congestive heart failure □ irregular heartbeat, arrhythmia □ bleeding problems □ Peripheral neuropathy □ MS or Xxxxxxxxx’x □ other neuro : □ osteoarthritis □ Lupus □ gout □ rheumatoid arthritis □ Other bone & joint: □ acid reflux, GERD □ inflammatory bowel disease □ hepatitis - Type □ liver disease □ other GI : □ kidney problems □ dialysis, kidney failure □ diabetes □ psoriasis □ high cholesterol or lipids □ thyroid problems □ sickle cell disease □ any skin ulcer □ Malignant hyperthermia Cancer : any type -- please specify Other medical problems NOT included above (explain) Patient Name: Date: Please check any and all insurance coverage you or your spouse has applicable in this case. □ Medicare □ Blue Shield □ Auto Accident □ Medicaid □ Major Medical □ Union Plan □ Blue Cross □ Worker’s Compensation □ Other Insurance Identification Number: Medicare/Medicaid Identification Number: _ Date of Accident: Insurance Company Name: Adjuster: Address/Phone: Claim #: Policy #: Effective Date: Name & Address: Phone #: Attorney Name & Address: Attorney Phone #: *Person to contact in an emergency (Name and Phone #): Patient Name: Date:
