Patient Health Questionnaire Chiropractic, Massage, Trigger Point Therapy, Salt Cave and more!Let us help you achieve your health goals! BOOK AN APPOINTMENT Leave this field blank Patient Health Questionnaire Dr. Janine D. Kelly (optional) 1762 Newbridge RoadBellmore, NY 11710 Patient Name Date Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 1. When did your symptoms start? Describe your symptoms and how they began: Indicate where you have pain or other symptoms (optional) 2. How often da you experience your symptoms? Choose Conctantly (76-100% of the day) Frequenty (51-75% of the day) Occasionally (26-50% of the day) lntermittently (0-25% of the day) 3. What describes the nature of your symptoms? Choose Sharp Shooting Dull ache Burning Numb Tingling 4. How are your symptoms changing? Choose Getting Better Not Changing Getting Worse 5. How bad are your symptoms at their? Please choose a number between 1 and 10. Choose 1 2 3 4 5 6 7 8 9 10 6. How do your symptoms affect your ability to perform daily activities? Choose No Complaints Mild, forgotton with activity Moderate, interferes with activity Limiting, prevents full activity Intense, preoccupied with seeking relief Sever, no activity possible 7. What activities make your symptoms worse? 8. What activities make your symptoms better? 9. Who have you seen for your symptoms? Choose No One Medical Doctor Other Chiropractor Physical Therapist Other a. When and what treatment? b. What tests have you had for your symptoms and when were they performed? Choose Xrays CTScan MRI Other Date Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 10. Have you had similar symptoms in the past? Yes No a. lf you have received treatment in the past for the same, or similar symptoms who did you see? Choose This Office Other Chiropractor Medical Doctor Physical Therapist Other 11. What is your occupation? Choose Professional/Executive White Collar/Secretarial Tradesperson Laborer Homemaker FT Student Retired Other a. what is your current work status? Choose Full-time Part-time Self-employed Unemployed Off work Other 12. What do you hope to get from your visit/treatment (select all that apply) Reduce symptoms Explanation of condition/treatment Resume/increase activity Leam how to take care of this on my own How to prevent this from occurring again Date Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 Patient Signature Start Drawing Clear Done Start Over Send
