This is a good overview of how this crash is interfering with your patients ADLs. This is also another way to monitor how your patient is progressing with care.
CONSITUTIONAL SYMPTOMS
- Good general health lately
- Recent weight change
- Fever
- Fatigue
- Headaches
EYES
- Eye disease or injury
- Wear glasses/contact lenses
- Blurred or double vision
- Glaucoma
EARS/NOSE/MOUTH/THROAT
- Hearing loss or ringing
- Earaches or drainage
- Chronic sinus problem or rhinitis
- Nose Bleeds
- Mouth sores
- Bleeding gums
- Bad Breath or bad taste
- Sore throat or voice change
- Swollen glands in neck
CARDIVASCULAR
- Heart trouble
- Chest pain or angina pectoris
- Palpitation
- Shortness of breath w/walking or lying flat
- Swelling or feet, ankles or hands
RESPIRATORY
- Chronic or frequent coughs
- Spitting up blood
- Shortness of breath
- Asthma or wheezing
GASTROINTENSTINAL
- Loss of appetite
- Change in bowel movements
- Nausea or vomiting
- Frequent diarrhea
- Painful bowel movements or constipation
- Rectal bleeding or blood in stool
- Abdominal pain
- Peptic ulcer (stomach or duodenal)
GENITOURINARY
- Frequent urination
- Burning or painful urination
- Blood in urine
- Change in force or strain when urinating
- Incontinence or dribbling
- Kidney stones
GENITOURINARY (cont’d)
- Sexual difficulty
- Male – testicles pain
- Female – pain with periods
- Female – irregular periods
- Female – vaginal discharge
- Female — # of pregnancies ____
- Female — # of miscarriages ____
MUSCULOSKELETAL
- Joint pain
- Joint stiffness or swelling
- Weakness of muscles or joints
- Muscle pain or cramps
- Back pain
- Cold extremities
- Difficulty in walking
INTEGUMENTARY (Skin, Breast)
- Rash or itching
- Change in skin color
- Varicose veins
- Breast Pain
- Breast lump
- Breast discharge
NEUROLOGICAL
- Frequent or recurring headaches
- Light headed or dizzy
- Convulsions or seizures
- Numbness or tingling sensations
- Tremors
- Paralysis
- Stroke
- Head Injury
PSYCHIATRIC
- Memory loss or confusion
- Nervousness
- Depression
- Insomnia
ENDOCRINE
- Glandular or hormone problem
- Thyroid disease
- Diabetes (insulin or non-insulin) circle
- Excessive thirst or urination
- Heat or cold intolerance
- Skin becoming drier
- Change in hat or glove size
HEMATOLOGIC/LYMPHATIC
- Slow to heal after cuts
- Bleeding or bruising tendency
- Anemia
- Phlebitis
- Past transfusion
- Enlarged glands
ALLERGIC/IMMUNOLOGIC
History or skin reaction or adverse reaction to:
- Penicillin or other antibiotics
- Morphine, demerol or other narcotics
- Novocain or other anesthetics
- Aspirin or other pain remedies
- Tetanus antitoxin or other serums
- Iodine, methiolate or other antiseptic
Other drugs/medications:
_____________________________________________
Known food allergies:
_____________________________________________
Environmental allergies:
_____________________________________________
Reviewed by: _____________________________________ Date: ___________________
Katz Chiropractic and Rehabilitation Clinic
Front Range Digital Motion X-Ray
2727 Pine Street, Unit 1
Boulder, Co 80302