Natural Health Center Clifton
physical health center Clifton

New Patient Form

Personal history form

ASSIGNMENT OF HEALTH PLAN BENEFITS AND RIGHTS
AS WELL AS AN APPOINTMENT AND/OR DESIGNATION AS MY PERSONAL REPRESENTATIVE
AND AN ERISA/PPACA REPRESENTATIVE AND BENEFICIARY

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(Where is the pain/problem, including radiation?)

(How severe is the pain/problem on a scale of 1-10 with 10 being the most severe? List your range of pain. When is it at its worst and best?)

(Does this pain/problem occur at a specific time?  Include frequency and how long it lasts)

(Ex: ankle problems due to knee problems ...)

(Heat, ice, over the counter medications, prescription medications, rest, exercise, physical therapy, chiropractic adjustments, massage, medical)

(How long have you had this pain/ problem? When did it start?)

(Example: stopped climbing steps as often)

(What makes the pain/problem worse or better? Going up and down stairs, brushing hair, etc)

(List medications)

(X-ray, CT scan, MRI,  None )

0

GENERAL INFORMATION

What prescriptions or over-the-counter medications are you taking?

Please list any x-rays, MRIs, CT scans, bone density, bone scans that you have had: 

Many times your problem area can be affecting other areas of your body, even ones that seem unconnected.  We view your body as a whole, connected unit.  Please give us the information below so we can best decide how to treat you for the best results for you.

PAINDISCOMFORTTENDERNESSTIGHTNESSMUSCLE SPASMLACK OF MOTIONNUMBTINGLINGPINS & NEEDLESWEAKNESSINFLAMMATION
HEAD
NECK
UPPER BACK
MID BACK
RIBS
LOW BACK
HIPS
KNEES
LOWER LEGS
ANKLES
FEET/TOES
SHOULDERS
ARMS
ELBOWS
FOREARMS
WRISTS
HANDS
FINGERS
PAINDISCOMFORTTENDERNESSTIGHTNESSMUSCLE SPASMLACK OF MOTIONNUMBTINGLINGPINS & NEEDLESWEAKNESSINFLAMMATION
HEAD
NECK
UPPER BACK
MID BACK
RIBS
LOW BACK
HIPS
KNEES
LOWER LEGS
ANKLES
FEET/TOES
SHOULDERS
ARMS
ELBOWS
FOREARMS
WRISTS
HANDS
FINGERS

ASIDE FROM YOUR MAJOR COMPLAINT ABOVE, WHICH OF THE FOLLOWING DO YOU

EXPERIENCE?    “R” = right       “Left” = left

Past Present
Rheumatoid arthritis
Ankylosing spondylitis
Bone fractures
Malignancy of the spine
Infection of the bones or joints
Myelopathy
Cauda Equina syndrome
Carotid artery problems
Aneurysm
Instability of joints
Benign tumors of the spine
Osteoporosis
Bleeding disorders
Nerve problems
Anticoagulants/blood thinning therapy
Dizziness
Drop Attacks
Double vision
Difficulty speaking
Difficulty swallowing
Nausea
Numbness
Nystagmus
Neck pain
Jaw pain
Headaches
Fainting spells
High blood pressure
Stroke
Transient ischemic attacks

Please read and check the following certification:

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THANKYOU

The Natural Health Center Doctors and Staff

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