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CLIN 2504 Health History Worksheet

CLIN 2504 Health History Worksheet - Health History...

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Health History Worksheet Form: WKS-A Version 3.1 Revised Oct 04, 2005 TG/se Page 1 of 2 © 2005 Life University College of Chiropractic Clinics Patient Name: File Number: Primary Clinician: Exam Date: Chief Complaint: ____________________________________________________________________________________ Date of Onset: Original and current episode: ________________________________________________________________ Mode of Onset: mechanism of injury and clinical characteristics ________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Past History of Chief Complaint: Has pt had this complaint/condition before? Compare to current complaint/condition. Same/Similar/Different – Explain: ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Palliative____________________________________________________________________________________________ Provocative _________________________________________________________________________________________ Quality, Intensity (initial and current) _____________________________________________________________________ ___________________________________________________________________________________________________ Radiates ____________________________________________________________________________________________ Site, Severity ________________________________________________________________________________________ Timing _____________________________________________________________________________________________ Relationship to other systems ____________________________________________________________________________ Previous/Current care and effect _________________________________________________________________________ ____________________________________________________________________________________________________________________________
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Health History Worksheet Page 2 Form: WKS-A Version 3.1 Revised Oct 04, 2005 TG/se Page 2 of 2 © 2005 Life University Past History Childhood illnesses, Trauma, illnesses, surgeries, prior diagnoses, medications _____________________________________
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