Patient History Form - Page 1 of 3
(All Information Confidential)
P. Anthony Chapdelaine, Jr., MD, MSPH, Founder and Medical Director
General and Alternative Medicine
229 Ward Circle Suite B12
Brentwood, TN 37027
(615) 377-6767
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Name__________________________________________ Date_______________
Parent/Guardian name (if child)_________________ ________ Your Birthdate_____________________
CURRENT MEDICAL HISTORY
Please describe briefly the health problem(s) you want to resolve. Describe symptoms that are bothering you now (headaches, indigestion, cramping, etc.)
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What other forms of therapy have you used for your health concern(s) (medical doctors, chiropractors, acupuncturists, etc.)? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
PAST MEDICAL HISTORY
Put an X next to the number for any of these conditions that you now have.
1. Anemia or blood disease 21. Arthritis or joint pain or gout
2. Neck/back injury or pain 22. Broken bones or bone injury
3. Orthotic appliances in shoe 23. Scoliosis (curved spine)
4. Operations (list below*) 24. Eye problems
5. Injuries needing medical help 25. Ear trouble (deafness)
6. Ringing ear, popping jaw 26. Sinus problems
7. Persistent cough 27. Recent weight gain or loss
8. Shortness of breath, asthma 28. Pneumonia, bronchitis
9. Racing heart 29. Heart disease, hypertension
10. Chest pain – angina 30. Rheumatic fever - heart murmur
11. Varicose veins or phlebitis 31. Poor circulation/swelling ankles
12. Allergy – hay fever 32. Skin disease – rash, moles
13. Cancer or tumor 33. Stomach/gallbladder trouble
14. Hemorrhoids/rectal bleeding 34. Kidney or bladder trouble
15. Painful, frequent urination 35. Hepatitis, liver trouble
16. Sugar or albumin in urine 36. Diabetes mellitus
17. Thyroid disease 37. migraine headache
18. Dizziness or fainting spells 38. Epilepsy/ convulsions
19. Fatigue Weakness
20. Other illnesses
Please list major Hospitalizations/Surgeries and approximate dates
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