Weis Chiropractic & Physical Therapy Center 10671 McSwain Drive
Cincinnati, OH  45241
Voice: 513.563.0414  FAX: 513.563.9540

Patient: ______________________________________

DOB: ___________ Date: ________________

1. Do you suspect you may be pregnant?    Yes ___ No ___
2. Do you have chest pain? Yes ___ No ___
3. Do you have any unusual bleeding or discharge? Yes ___ No ___
4. Do you have a nagging cough or hoarseness? Yes ___ No ___
5. Do you have headaches for hours or days? Yes ___ No ___
6. Do you have blurred vision? Yes ___ No ___
7. Do you have pain in your jaw or face? Yes ___ No ___
8. Do you have dizziness? Yes ___ No ___
9. Do you suffer from slurred speech? Yes ___ No ___
10. Do you have mid-back pain? Yes ___ No ___
11. Do you have shortness of breath? Yes ___ No ___
12. Do you fatigue easily? Yes ___ No ___
13. Do you suffer from depression? Yes ___ No ___
14. Does your pain ever wake you from a sound sleep? Yes ___ No ___
15. Are you losing weight without trying? Yes ___ No ___
16. Are you coughing up blood or noticing it in your urine or stool? Yes ___ No ___
17. Do you smoke? Yes ___ No ___       If yes, how long?  _______ How many packs per day? ______
18. Do you drink alcohol? Yes ___ No ___  If yes, how much? ______________________________________________
19. Are you allergic to any foods or drugs? Yes ___ No ___ If yes, what? ____________________________________
20. Substance abuse? Yes ___ No ___
21. What prescription medication(s) are you currently taking, if any?

    ( ) High blood pressure medication	( ) Muscle Relaxers
    ( ) Anti-inflammatory medication	( ) Blood thinners
    ( ) Pain Medication	( ) Birth control pills
    ( ) Other




22. What over the counter medication(s) have you been taking?

    _____________________________________________________________________________

    _____________________________________________________________________________

     

23. List any of your past surgical procedures, if any, and the date in which they were performed.

    _____________________________________________________________________________

    _____________________________________________________________________________

     

24. List any past injuries, if any, and the date in which they occured.

    _____________________________________________________________________________

    _____________________________________________________________________________

     

25. Are you seeing another doctor for any other reason? Yes ____ No ____ Comments:

    _____________________________________________________________________________

    _____________________________________________________________________________

     

26. Did you or your mother or father have any of the following?  (Circle M for mother,
    F for father, S for self):

    High blood pressure	M	F	S
    Heart Attack	M	F	S
    Emphysema	M	F	S
    Seizures-Convulsions	M	F	S
    HIV Positive	M	F	S
    Asthma	M	F	S
    Diabetes	M	F	S
    Kidney disease	M	F	S
    Ulcer or stomach problems	M	F	S
    Stroke	M	F	S
    Arthritis-Rheumatism	M	F	S
    Mental illness	M	F	S
    Throid disease	M	F	S
    Circulation problems	M	F	S
    Cancer	M	F	S