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Chiropractic Clinic Dr Nassim Saba-Sayah, Via Madonnina, 10 20121 Milan (Italy)
PATIENT MEDICAL PROFILE
Please complete this form by marking the relevant boxes with an [X]
Milan, .......................
PERSONAL DATA
Name ................................................................................
Surname ..........................................................................
SSN (Codice Fiscale)…….…………………………………
Place of birth……...............................................................
Date of birth ...... / ...... / .......
First language (only if born or resident abroad): ..........................................................................................
Height: cm. ..........Weight: kg. ..........
[ ] right-handed [ ] left-handed [ ] ambidextrous
Occupation ....................................................................... ..........................................................................................
Address Street ...................................................... No. ..........
City..............................................Post code....................
Telephone
Home................................................................................
Work…..............................................................................
Mobile...............................................................................
E-mail ..............................................................................
Contact in case of emergency Name ................................................................................
Relationship with the patient...........................................
Phone No..........................................................................
FURTHER INFORMATION
How did you find our Center? ........................................................................................................................................ ....................................................................................................................................................................................... Job related fatigue / stress ….….................................................................................................................................... ....................................................................................................................................................................................... ....................................................................................................................................................................................... ....................................................................................................................................................................................... .......................................................................................................................................................................................
Physical activities Frequency
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2. Leisure activities Frequency
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CLINICAL DATA
Physician’s name, address and phone number .......................................................................................................................................................................................
Last examination date: ...... / ...... / ....... Name of the Specialist ..........................................................
Reason for the examination...........................................................................................................................................
Date of the last chiropractic examination: ...... / ...... / ....... Name of the Specialist ...................................................
Reason for the examination...........................................................................................................................................
What is your main health complaint at present?.....…………........................................................................................
Why have you turned to our Centre? ………................................................................................................................
On a scale from 1 (low) to 10 (high), what is the current intensity of your disorder? .................................................
When did the disorder first manifest itself? ...... / ...... / .......
With what symptoms?.................................................................................................................................................. Had it already manifested itself in the past? No [ ] Yes [ ] Specify: ….............................................................................................................................................................
What do you think caused the problem? ……………...............................................................................................
Did the symptoms manifest themselves: [ ] suddenly [ ] gradually
Frequency of the Disorder : [ ] continuous [ ] every hour [ ] several times a day
[ ] other ...................................................
The problem / episode lasts an average of [ ] ..... minutes [ ] ..... hours [ ] ..... days The problem interferes with your: [ ] work [ ] sleep [ ] daily activities [ ] leisure activities
What makes you feel better? ....................................................................................................................................
What makes you feel worse? ....................................................................................................................................
What other therapies [ ] have you received [ ] are you receiving, for this same problem? :
[ ] drugs [ ] surgery [ ] other: ..........................................................................................................................
3. Mr / Ms ................................................................................ Milan, .......................
The problem gets worse when you:
[ ] are sitting [ ] are standing
[ ] lift weights
[ ] make a rotation movement or other [ ] : ...........................................................................................
[ ] walk [ ] drive [ ] do sports / gym
[ ] fast [ ] eat [ ] eat a particular food or drink: .....................................
[ ] other .........................................................................................................................................................................
Have you been advised against certain [ ] foods or drinks [ ] movements [ ] activities
[ ] other: .......................................................................................................................................................................
Have you had any accidents?
[ ] No [ ] Yes , in which case please specify:
[ ] car accident ( on ...... / ...... / ....... )
[ ] work accident ( on ...... / ...... / ....... )
[ ] other ......................................................................................................................... ( on ...... / ...... / ....... )
FAMILY CASE HISTORY
Have any of your family members suffered from:
[ ] Alzheimer’s [ ] Parkinson’s [ ] TBC [ ] diabetes [ ] thyroid diseases
[ ] kidney diseases [ ] hypertension [ ] heart diseases [ ] stroke [ ] high cholesterol
[ ] Musculoskeletal disorders [ ] cancer [ ] anxiety or depression
[ ]
other: .........................................................................................................................................................................
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4. Using the symbols below, indicate the areas affected by the pain:
1 symbol, e.g. ( + ), for a light pain 2 symbols, e.g. ( ++ ), for a moderate pain 3 symbols, e.g. ( +++ ), for an intense pain 4 symbols, e.g. ( ++++ ), for an unbearable pain
Symbols: ( + ) numbness ( # ) hot – burning pain ( O ) pulsating pain
( / ) sharp – stabbing pain ( > ) intense pain ( K ) cramps
( Δ ) other ...................................................
( ) widespread – radiating pain (draw an arrow from where the pain starts to where the radiation travels)
5. PERSONAL MEDICAL HISTORY
Mr /Ms ................................................................................ Milan,.......................
COMPLAINT PRESUMED CAUSE SYMPTOMS START DATE
[ ] recent change in appetite
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[ ] swallowing difficulties
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[ ] recent significant weight change
how many kg. .................
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[ ] anemia
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[ ] gastrointestinal complaints list: ...............................................
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[ ] nausea, vomiting
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[ ] precancerous or cancerous conditions
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[ ] recurring allergies list: ...............................................
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[ ] evacuation disorders list: ...............................................
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[ ] urinary disorders list: ...............................................
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[ ] kidney disorders list: ...............................................
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[ ] diabetes
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[ ] breathing difficulties
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Exposure to:
[ ] chemicals
[ ] high levels of pollution
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6.
COMPLAINT PRESUMED CAUSE SYMPTOMS START DATE
[ ] chest tightness or pain
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[ ] tachycardia, arrhythmia o palpitations
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[ ] hypertension
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[ ] edema and bleeding tendency
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[ ] headache
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[ ] ear disorders
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[ ] temporomandibular joint dysfunction
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[ ] pain in temples
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[ ] bruxism (teeth grinding)
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[ ] visual impairment list: ...............................................
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[ ] fainting
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[ ] epilepsy
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[ ] vertigo
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[ ] giddiness
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[ ] gland enlargement or dysfunction
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[ ] irritability and nervousness
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[ ] anxiety or depression
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[ ] frequent memory lapses
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DEPENDENCIES QUANTITY START DATE DENTAL PROBLEMS AND PROSTHESES START DATE
[ ] smoke [ ] alcohol [ ] medications
[ ] drugs
[ ] other ......................... ......................... .........................
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[ ] Any unresolved dental problems :
list ...................................................
[ ] Do you wear braces or a bite guard?
reason.................................................... [ ] Do you wear other prostheses?
reason.................................................... [ ] Do you use orthopedic prostheses or implants?
reason.................................................
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7. Mr / Ms ................................................................................ Milan, .......................
COMPLAINT PRESUMED CAUSE SYMPTOMS START DATE
[ ] insomnia
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[ ] other psychological disorders specify: .............................................
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[ ] osteoporosis
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[ ] rheumatoid arthritis
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[ ] other bone and joint disorders
list: ...............................................
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[ ] infectious diseases list: ...............................................
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[ ] malaise, fatigue, weakness
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[ ] other disorders list: ...............................................
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8.
Were you delivered by Caesarean section? [ ] No [ ] Yes
Have you had any surgical operations?
[ ] No [ ] Yes, (specify) ……….…..........................................................................................................................
Please list any admissions to private or public hospitals, the reasons for admission and the dates: .......................................................................................................................................................................................
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Please list any drugs you are currently taking: .......................................................................................................................................................................................
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How would you describe your sleep quality? [ ] good [ ] adequate [ ] poor
Estimate how many hours you sleep each night: .........
Preferred sleeping position: [ ] on your back [ ] on your tummy [ ] on your side Are you on a specific diet? [ ] No [ ] Yes, (specify) .........................................................................................
How many cups of coffee do you drink a day? ........
Are you currently pregnant? [ ] No [ ] Yes (How many months pregnant are you? .............. )
.................................................................................................. ................................... Signature of the Patient date
.................................................................................................. ................................... Signature of the Parent or Legal Guardian date
9. Mr / Ms ....................................................................
FURTHER PATIENT INFORMATION
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Mr / Ms....................................................................
FOR THE DOCTOR
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