NEW PATIENT FORM

FERNANDO CHIROPRACTIC AND WELLNESS CENTER

DR. ANTONIO C. FERNANDO

1244 W. Hamilton Street Suite 102-104

Allentown, PA 18102

(484) 538-3875

CASE HISTORY


Name _______________________________________Age _________Date __________

Address _______________________________________ City ________________ State_____ Zip________

Phone (Home/Cell) __________________ Date of Birth _____________ Sex: M F Marital Status: S M D W

Social Security # _____________________ EMAIL ____________________________________________

Occupation Employer _______________________________________ Phone (Work)__________________

Insurance Company_________________________________________ Phone________________________

Insured’s Name _________________________________ Insured’s Date of Birth _____________________

Insured’s ID. # or S.S. # __________________________________

Spouse’s Name _______________________Spouse’s Occupation _________________________________

Spouse’s Employer __________________________Spouse’s Phone (Work)__________________________

Spouse’s Insurance Co. ______________________________________ Phone________________________

Spouse’s Social Security # ________________________________

Present condition due to an injury? __ Yes __ No __ On the Job __ Auto Accident __ Other _____________

Has the accident been reported? __ Yes __ No __ To Employer __ Auto Carrier __ Other ________________

HEALTH REPORT:

Reason for seeking care: ___________________________________________________________________

List any other doctors seen for this: __________________________________________________________

List any diagnosis and type of treatment: _________________________________________________

Have you had similar accidents or injuries before? __ Yes __ No If yes, explain: ______________________

List the names of any relatives that have or have had a similar problem: _____________________________

Have you or any relative received chiropractic treatment previously? __ Yes __ No

If yes, explain: ______________________________________________________

Have you been treated for any health condition by a physician in the last year? __ Yes __ No

If yes, explain: ______________________________________________________

Are you currently taking medication? __ Yes __ No list medications: _______________________________ _______________________________________________________________________________________

Have you taken medication in the past? __ Yes __ No list medications _______________________________

List conditions you are taking medications for: ______________________________________________________

List the approximate dates of any surgery or treated conditions:__________________________________________

_____________________________________________________________________________________________

Family History: Health conditions, age of death and cause of death.

Father: ______________________________________________________________________________________

Mother: _____________________________________________________________________________________

Brother/s & Sister/s: ___________________________________________________________________________

Do you smoke Y/N ____ •Alcohol Y/N __Daily __Weekly __Social Occasions •Caffeinated drinks per day ____

Do you take Vitamins/Supplements Y/N If yes, type and how often _____________________________________

Please circle degree of pain, 0 none, 10 severe pain.

0 1 2 3 4 5 6 7 8 9 10

What activities aggravate your condition/pain?___________

What activities lessen your condition/pain?______________

Is this condition worse during certain times of the day? Y/N

Is this condition interfering with Work?__________ Sleep?__________Routine?_______Other?____________

Is this condition progressively getting worse?___________

Medications __________________________________________________________________________________


Please mark each item below for each sign or symptom you presently have or previously had:

GENERAL SYMPTOMS

__ Convulsions__ Dizziness__ Fainting__ Headache__ Nervousness __ Numbness __ Wheezing

MUSCLES & JOINTS

__ Low Back Problems__ Pain between Shoulders__ Neck Problems

__ Arm Problems__ Leg Problems__ Swollen Joints__ Painful Joints__ Stiff Joints__ Sore Muscles

__ Weak Muscles__ Walking Problems__ Sprains/Strains__ Broken Bones

CARDIO-VASCULAR

__ High Blood Pressure__ Heart Attack__ Pain over Heart__ Poor Circulation__ Heart Trouble__ Rapid Heart

__ Slow Heart__ Strokes__ Swelling Ankles__ Varicose Veins

EAR/NOSE/THROAT

__ Earache__ Ear Noises__ Enlarged Thyroid__ Frequent Colds__ Hay Fever__ Nasal Blockage

__ Nose Bleeds__ Pain Behind Eyes__ Poor Vision__ Sinusitis__ Sore Throats__ Tonsillitis

GASTRO-INTESTINAL

__ Belching/Gas__ Colon Problems

__ Constipation__ Diarrhea__ Excessive Hunger__ Excessive Thirst__ Gall Bladder Trouble

__ Hemorrhoids__ Liver/Gallbladder__ Nausea__ Abdominal Pain__ Ulcer__ Poor Appetite

__ Poor Digestion__ Vomiting__ Vomiting Blood__ Black Stool__ Bloody Stool__ Weight Loss/Gain

RESPIRATORY

__ Asthma__ Chronic Cough__ Difficulty Breathing__ Spitting Blood__ Spitting Phlegm

GENITO-URINARY

__ Blood in Urine__ Frequent Urination__ Kidney Infection__ Painful Urination__ Prostate Problems__ Loss of Bladder Control

SKIN OR ALLERGIES

__ Boils__ Bruising Easily__ Dryness__ Eczema/Rash/Dermatitis__ Hives__ Itching__ Sensitive Skin__ Allergy ______________

FOR WOMEN ONLY

__ Birth Control ____ Hormone Replacement__ Cramps/Backaches

__ Excessive Flow__ Hot Flashes__ Irregular Cycle

__ Miscarriage__ Painful Periods__ Vaginal Discharge__ Breast Pain 

Pregnant at this Time Y/N


I hereby certify that the statements and answers given on this form are accurate to the best of knowledge and understand it is my responsibility to inform this office of any changes in my health.

I agree to allow this office to examine me for medical necessity of treatment.

Patient Signature______________________________________________________Date_________________________