Document the patient's past health history, including as applicable his or her general health, prior illnesses, injuries, hospitalizations, current medications, and surgical history.
Example: Patient states she is currently being treated for hypertension, asthma, and hay fever. Patient denies hospitalizations or surgeries. Currently takes Cozaar 50 mg, BID, Theo-dur 100 mg, BID and Allegra 50 mg, BID.
The patient may provide this information on a form. If you use a form to collect this information from patients, be sure to review and clarify the responses. For example, patients may not know correct names of medications and may describe them instead: I take one green pill and two blue ones.
Also ensure patient is not providing contradictory information. For example, if the patient is presenting for a spinal manipulation but denies back trouble, there is no medical necessity for the treatment.
A chiropractic assistant or other staff member may review or collect this information
for you.