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) PATIENT INSURANCE INFORMATION: 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 Major Medical or Auto Insurance: Date of Accident: Insurance Company Name: Adjuster: Address/Phone: Claim #: Policy #: Effective Date: Primary Care Physician: Name & Address (if known): Phone #: LEGAL INFORMATION (Workers Comp / Auto accident): 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: Results Chiropractic, LLC Xxxxx X. Xxxxxxxxxx, DC 00000 Xxxxx Xxxxx Xxxx, Xxxxx 0X (P) 302.404.0000 (F) 302.358.2453 PERSONAL INJURY QUESTIONNAIRE Non- Automobile or Workers Compensation Please answer all of the following questions completely.
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: PATIENT INSURANCE INFORMATION: 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: _ Major Medical or Auto Insurance: Date of Accident: Insurance Company Name: Adjuster: Address/Phone: Claim #: Policy #: Effective Date: Primary Care Physician: Name & Address: _ Phone #: LEGAL INFORMATION: Attorney Name & Address: Attorney Phone #: *Person to contact in an emergency (Name and Phone #): Patient Name: Date: XXXXXXX CHIROPRACTIC CENTER DIRECT ASSIGNMENT OF BENEFITS & RIGHTS
Family History. Pedigree
Family History. Tell me about your family (i.e. child's parents, siblings, grandparents, and other extended family) I verify that the above assessment was discussed with the parent(s) of Signature of Director Date Signed I verify that the director appropriately relayed the information concerning my child's assessment. Signature of Parent Date Signed
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): OBSTETRICAL HISTORY Did you have difficulty falling pregnant? Did you have miscarriages before falling pregnant? How old were you when you fell pregnant? What was moms general state of health during pregnancy eg viral infections, illness, German Measles, stress, excessive morning sickness, haemorrhage? Were any prescription drugs taken during your pregnancy? Where there any blood type complications during your pregnancy? What was duration of pregnancy? Were there any complication relating to the birth? NEONATAL PERIOD Birth Weight? Breast or Bottle fed? Where there any feeding problems: Were there any difficulties introducing solids? Developmental Milestones First smile: Held head up first time: Sat unaided: Stood unaided: Crawled: Walked unaided: Began babbling: First words: Sentences: Understanding and response to commands: MEDICAL HISTORY Has your child had any significant illnesses? Has your child ever been in hospital (if yes please give a brief description)? Has your child experienced any recurrent illnesses (eg. ear/nose throat infections)? Does your child have a history of seizures, convulsions or epilepsy? Is your child on any medication at present (if yes supply name and dosage)? Is your child currently attending any therapies? (If yes please supply therapist name and contact number) Is your child’s immunizations up to date? Does your child have any allergies? Does your child have any physical / coordination difficulties? Does your child have any visual / hearing difficulties? SOCIAL EMOTIONAL DEVELOPMENT Describe the relationship your child has with immediate family members: Describe any behavioral or emotional difficulties your child may have: How would you describe your child’s personality? Please indicate if your child has difficulties with any of the following: Sleeplessness: Tactile Defensive: Auditory Defensive: Oral Sensitivity: Self Stimulatory Behavior’s: Easily Frightened:
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. 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. Tell me about your family (i.e. child’s parents, siblings, grandparents, and other extended family) I verify that the above assessment was discussed with the parent(s) of Signature of Director Date Signed I verify that the director appropriately relayed the information concerning my child’s assessment. Signature of Parent Date Signed Additional Comments: lBreAch eArly eArning center Child Health Record Child’s Name: Nickname: Birth date: Child’s Physician: Is your child currently under the care of a physician? Please describe your child’s current physical health ☐ Good ☐ Fair ☐ Poor Medical Conditions: (Please check all that apply) Has your child had any of the following? ☐ Heart Murmur ☐ Bronchitis ☐ Hearing ☐ Hyperactive ☐ Surgeries ☐ Hepatitis ☐ Convulsion/Epilepsy ☐ HIV/Aids ☐ Heart Disease ☐ Asthma ☐ Hospitalization ☐ Impairment ☐ Polio ☐ Sinus Problems ☐ Diabetes ☐ Cancer ☐ Kidney/Liver Problems Has your child had any serious medical conditions not listed above? If yes, please explain: Does your child have any Disabilities? If yes, please explain: Has your child had more than two ear infections in a year? Has your child had tonsillitis? Has your child ever had reaction to the Tuberculosis skin test? ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No Has your child ever been near anyone suffering from tuberculosis?☐ Yes ☐ No Does your child suffer for any hemophiliac disorders? ☐ Yes ☐ No Does he/she have seizures fits or shaking spells? Does your child have speech or hearing problems? Does your child have trouble with his eyes or seeing? Does your child have speech or hearing problems? Is your child able to play as hard as other children? Does your child have tubes in his/her ears? Does your child get along with other children? Is he/she usually happy? Does your child have herpes? Does your child have any special problems not indicated above? ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No If yes please explain: When did your child last see a doctor? Month: Year: Has your child ever been in the hospital overnight? ☐ Yes ☐ No If yes, why? Has your child had any operations? ☐ Yes ☐ No If yes, please explain? Does your child have any medical conditions that the emergency room would need to know about ( such as asthma, diabetes, epilepsy, etc. ) ☐ Yes ☐ No If yes, please explain: Is your child on any medication? ☐ Yes ☐ No If yes please list all medication both over-the-counter and prescription: I understand th...
Family History. Information about people living in the household: NAME Date of Birth (Age) Relationship
Family History. Describe and discuss family composition, health of family members including similar disease/disorders in other members of family, the primary caretaker(s) and their role in providing for the DDDS claimant’s medical, emotional, and daily activity needs. Include longitudinal history of relations with parents, family, peers, etc.
