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Bodyfocushealthgroup.com.au

CONFIDENTIAL PATIENT CASE HISTORY

As a multidisciplinary practice providing comprehensive care, we focus on your ability to be
healthy. Our goals are: firstly, to address the issues that brought you to this practice; secondly,
to treat the cause of your condition (not just treat the symptoms or place a temporary patch
over your condition); and thirdly, to offer you the opportunity of improved health potential and
wellness services in the future. Answering the following questions will give us a profile of your
health, and ensure that we optimise your outcome and deliver treatment excellence.

What is your major complaint?
_________________________________________________________________
Draw on the sketch below the area(s) where you feel your problem to be.


When did your symptoms start?
_________________________________________________________________
Was it a gradual or sudden onset?
_________________________________________________________________
Have you had this or a similar problem in the past?
_________________________________________________________________
If you are experiencing pain, please tick the words that best describe your
pain:
Confidential Patient Case History Form Version 1.0,
Do you get?
needles
Since the problem started it is:
 About the same  Getting better  Getting worse What makes your pain worse?
Your pain interferes with:
What type of work do you do?
__________________________________________________________
Any Bladder or Bowel changes since this episode started?
__________________________________________________________
Do you experience any nausea, dizziness, difficulty swallowing, changes in
vision, or fainting spells, fever, skin rashes associated with your
symptoms?
__________________________________________________________
Other health professionals seen for this problem (please list):
Medical
Doctor____________________________________________________________
Specialist
Doctor/Surgeon_____________________________________________________
Physiotherapist/Chiropractor
__________________________________________________________________
Other
__________________________________________________________________

List any medications you are taking
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

Have you ever taken oral cortisone or prednisone (including asthma
medications such as pulmicort, symbicort, flixotide & seretide)? Y/N
Are you pregnant? Y/N

Confidential Patient Case History Form Version 1.0, Do you have or have you ever had?: (please tick)

 High blood pressure
Patient’s Signature: _______________ Print Name: ______________________ Practitioner's Signature: _________________ Date: _____________________ Confidential Patient Case History Form Version 1.0,

Source: http://www.bodyfocushealthgroup.com.au/wp-content/uploads/2013/04/Patient-Case-History-Form.pdf