Dr. George Hawkins

Confidential Patient Health Record Date

PERSONAL HISTORY

Name:

Address:

City: State: ZIP

Home Phone: Cell Phone:

Work Phone: Birth Date: Age:

Email:

Business/Employment:

Type of Work:

Name of Spouse: Referred To this Office By:

Name Number of Emergency Contact: Name

Relationship:

CURRENT HEALTH CONDITION

PAST HEALTH HISTORY

Please Describe:
Major Surgery/Operations/Accidents: Include approximate dates if possible.

Previous Chiropractic Care: None Doctor's Name & Approximate Date of Last Visit

Below are lists of diseases, which may seem unrelated to the purpose of your appointment. However, these questions must be answered carefully, as these problems can affect your overall course of care.

CHECK ANY OF THE FOLLOWING DISEASE YOU HAVE HAD:

Pneumonia Mumps Influenza Rheumatic Fever Small Pox
Chicken Pox Arthritis Polio Diabetes Epilepsy Whooping Cough
Anemia Cancer Thyroid Heart Measles Mental Disorders
Lumbago Eczema HIV Shingles Mono Chronic Fatigue
Pleurisy Tuberculosis

Fill-in Daily Consumption: Coffee Tea Alcohol
Cigarettes White Sugar

CHECK ANY YOU HAVE HAD IN THE LAST 6 MONTHS: MUSCULO-SKELETAL SYSTEM

Low Back Pain Neck Pain Arm Pain
Joint Pain/Stiffness Pain Between Shoulders Walking Problems
General Stiffness Difficult Chewing/Clicking Jaw

NERVOUS SYSTEM

Nervous Numbness Paralysis Dizziness Stress
Confusion/Depression Fainting Convulsions
Cold/Tingling Extremities Forgetfulness

GENERAL

Fatigue Allergies Headaches Fever Loss of Sleep

GASTRO-INTESTINAL SYSTEM

Poor Appetite Excessive Hunger Excessive Thirst Frequent Nausea Vomiting
Diarrhea Constipation Hemorrhoids Liver Trouble Gall Bladder Problems Colitis Weight Trouble
Gas/Bloating After Meals Heartburn Black/Bloody Stool

GENITO-URINARY SYSTEM

Bladder Trouble Painful/Excessive Urination
Discolored Urine Prostatitis

CARDIO VASCULAR SYSTEM

Chest Pain Short Breath Ankle Swelling
Blood Pressure Problems Irregular Heartbeat Heart Problems
Lung Problems/Congestion Varicose Veins Stroke

EARS, EYES, NOSE, THROAT

Vision Problems Dental Problems Sore Throat
Ear Aches Hearing Difficulty Stuffed Nose
Sinus Trouble

FEMALE REPRODUCTIVE SYSTEMS

Menstrual Irregularity Menstrual Cramps Vaginal Pain/Infection
Breast Pain Lumps Cysts
When was your last period? Are you Pregnant? Yes No Not Sure

MALE REPRODUCTIVE SYSTEMS

Prostate Problems Sexual Dysfunction Other Problems

FAMILY HISTORY

The following members have a same or similar problem as I do:
Mother Father Brother Sister Spouse Child None

Patient Signature (if under the age of 18, the parent/legal guardian's signature) signifies consent to treatment for the patient and/or minor. It also signifies that I clearly understand and agree that all services rendered to me and/or my minor are charged directly to me and that I am personally responsible for payment at time of service and that this creates the ability for the doctor to pass savings on to me as reflected by reduced fees as compared to the usual and customary fees for these similar services. I acknowledge that Dr. Hawkins has explained and disclosed the benefits and risks associated with chiropractic treatment. I also understand that my confidential medical records will be treated in accordance to the standards and practices of the HIPPA codes. I hereby authorize Dr. Hawkins, The Concierge Chiropractor, to treat my condition, as he deems appropriate.