C ase History
Nam e _____________________________________________________________________
Medicare
Date _________________
Street _______________________________ City ______________________ State _________ Zip ______________
Mailing Address (if different than street address): _________________________________________________________
H. Phone _______________________ W . Phone _______________________ Cell Phone: _______________________
E-m ail address: _____________________________________ Birth Date _____________ Age _________ Sex: M F
If fem ale, is there a possibility that you m ight be pregnant? YES NO Marital Status: M S W D No. of children _____
Occupation _______________________________________ Em ployer ________________________________________
Spouse's Nam e _____________________________ Spouse's Em ployer/Occupation _____________________________
W ho should we call in an em ergency? Nam e ____________________________________ Phone _________________
List any tim es you were hospitalized ____________________________________________________________________
_________________________________________________________________________________________________
List any surgeries (include date) _______________________________________________________________________
_________________________________________________________________________________________________
Previous Injuries: ___________________________________________________________________________________
_________________________________________________________________________________________________
Yes No Health Habits Yes No
o o o o Do you drink 2 or m ore alcoholic beverages
o o Do you m aintain a good posture?
Do you exercise regularly? each day?
o o Do you eat 5 or m ore servings of fruits or o o Do you take nutritional supplem ents?
vegetables each day? o o Do you consider yourself to be healthy?
o o Do you sm oke? o o Do you frequently feel em otionally stressed?
In the following list, please check all of the conditions that you have experienced in the past year.
HEAD o Num bness or tingling in o Pain in hip joint o Difficulty starting urination
o Headache hands o Pain down upper leg o Night urination
o Migraine o Loss of strength in arm s o Pain down below knee GENERAL
o Head feels heavy o Loss of strength in hands o Pain in both legs o Nervousness
o Vision problem s BACK o Knee pain o Irritable
o Dizziness o Upper back pain o Leg cram ps o Mood swings
o Hearing problem s o Mid-back pain o Num bness or tingling in o Depression
o Ringing in ears o Rib pain legs o Fatigue
NECK o Pain when breathing o Num bness or tingling in o Difficulty sleeping
o Neck pain o Low back pain toes o Diabetes
o Grinding sounds in neck o Swollen ankles o Cancer
ABDOM EN - DIGESTION
SHOULDERS o Nervous stom ach W OM EN ONLY o Breathing problem s
o Pain in shoulders o Ulcers o Menstrual pain o Asthm a
o Can't raise arm o Constipation o Cram ping o Allergies
o Heart burn o Irregularity o Sinus trouble
ARM S & HANDS o Menopause o Epilepsy
o Pain in arm o Hiatal Hernia
o Nausea o Pre-m enstrual Syndrom e o High blood pressure
o Pain in hands o Difficulty losing weight
o Num bness or tingling in HIPS, LEGS & FEET M EN ONLY
arm o Pain in buttocks o Urinary frequency
Head, Neck, Arm or Hand Complaints
Describe Com plaint:___________________________________________________________________
W hat does it feel like: Sharp Dull Burning Tingling Stabbing Num b Aching W eak
W hen did it start? __________________ W hat caused it or what were you doing? ________________________________
How often do you feel it? Is it Constant o, OR _________ tim es per o Day, o W eek, o Month, or o Year
W hat m akes it worse? _____________________________ W hat m akes it better? _______________________________
Circle the numbers in the scale below to indicate how bad this complaint is. A “0" would be no complaint and a “10" would be extreme
discomfort.
0 1 2 3 4 5 6 7 8 9 10
Is it worse in the: o Morning o Mid-day o Evening o Doesn’t Matter. Did it occur o Suddenly or o Gradually?
Does anyone else in the fam ily have this problem ? ________________________________________________________
Notes: ____________________________________________________________________________________________
Upper and Middle Back Complaints
Describe Com plaint: _________________________________________________________________________________
W hat does it feel like: Sharp Dull Burning Tingling Stabbing Num b Aching W eak
W hen did it start? __________________ W hat caused it or what were you doing? ________________________________
How often do you feel it? Is it Constant o, OR _________ tim es per o Day, o W eek, o Month, or o Year
W hat m akes it worse? _____________________________ W hat m akes it better? _______________________________
Circle the numbers in the scale below to indicate how bad this complaint is. A “0" would be no complaint and a “10" would be extreme
discomfort.
0 1 2 3 4 5 6 7 8 9 10
Is it worse in the: o Morning o Mid-day o Evening o Doesn’t Matter Did it occur o Suddenly or o Gradually?
Does anyone else in the fam ily have this problem ? ________________________________________________________
Notes: ____________________________________________________________________________________________
Lower Back, Hip and Leg Complaints
Describe Com plaint: _________________________________________________________________________________
W hat does it feel like: Sharp Dull Burning Tingling Stabbing Num b Aching W eak
W hen did it start? __________________ W hat caused it or what were you doing? ________________________________
How often do you feel it? Is it Constant o, OR _________ tim es per o Day, o W eek, o Month, or o Year
W hat m akes it worse? _____________________________ W hat m akes it better? _______________________________
Circle the numbers in the scale below to indicate how bad this complaint is. A “0" would be no complaint and a “10" would be extreme
discomfort.
0 1 2 3 4 5 6 7 8 9 10
Is it worse in the: o Morning o Mid-day o Evening o Doesn’t Matter Did it occur o Suddenly or o Gradually?
Does anyone else in the fam ily have this problem ? ________________________________________________________
Notes: ____________________________________________________________________________________________
In the box below, please mark the areas of pain or other symptoms.
Check the following activities that you have had trouble perform ing since your com plaints started and rate the difficulty.
No Som e Very Can’t No Som e Very Can’t
Problem Difficulty Difficult Do Problem Difficulty Difficult Do
......... ..
W alking o o o o Gardening/Yard W ork o o o o
Standing ........ o o o o Sweeping/Mopping . .. o o o o
Sitting . . . . . . . . . . o o o o Sexual Activity . . . . . . o o o o
Sleeping . . . . . . . . o o o o Em ploym ent . . . . . . . . o o o o
Driving . . . . . . . . . o o o o Shopping . . . . . . . . . . o o o o
Clim bing Stairs . . . . o o o o Sports . . . . . . . . . . . . o o o o
Lifting . . . . . . . . . . o o o o Exercise . . . . . . . . . . o o o o
Cooking . . . . . . . . . o o o o Hobbies / . . . . . . . . . . o o o o
Fixing Hair . . . . . . . o o o o Leisure Activities
Other Affected Activities
____________________________________________ o Som e Difficulty o Very Difficult o Can’t Do
____________________________________________ o Som e Difficulty o Very Difficult o Can’t Do
Have you ever received Chiropractic care? Y / N If yes where? _____________________________________________
List other doctors consulted for present com plaints:
Nam e __________________ W hen _________ Diagnosis____________________Treatm ent ______________________
Nam e __________________ W hen _________ Diagnosis____________________Treatm ent ______________________
Drugs you now take: ________________________________________________________________________________
_________________________________________________________________________________________________
Inform ed Consent: The role of a chiropractor is to help restore function to the spine through chiropractic adjustm ents. As this
is done, m ost patients experience im provem ent in spine related conditions. The speed or extent of im provem ent is to a large
degree dependent upon the inherent recuperative abilities of each patient. Som e experience very rapid results, som e slower
results. A sm all percentage receive no outward benefit. Chiropractic does not treat pain, although m ost patients do experience
reduced pain. Occasionally som e patients experience a short-term increase in pain. W e also do not diagnose and treat
diseases other than those directly related to or caused by spinal m isalignm ents. If you have other conditions that you wish
evaluated, please consult with your m edical doctor. As with any health care procedure, chiropractic adjustm ents have som e
risk. Increased risk often results from som e underlying weakness or condition possessed by the patient that is not readily
apparent through routine exam ination. Serious com plications to chiropractic adjustm ents are considered by m ost authorities
to be very rare, occurring once per one m illion adjustm ents. By individuals not properly trained, the risk can be m uch greater.
W hen evaluating risks and benefits of health care procedures, you m ust consider the risk of not receiving care. Patients who
choose m edical care rather than chiropractic choose to accept the even greater risks associated with m any m edications and
surgical procedures. Most chiropractic experts and patients agree that the benefits of chiropractic far outweigh the risks,
however there are som e risks. During the course of your care, you will be required to position yourself on the treatm ent tables
and turn over on the tables. Although very rare, there have been occasions where patients have fallen off of a treatm ent table.
By signing below you acknowledge that you understand the above risks and agree to continue with your care. You also
acknowledge that you are capable of positioning yourself on the tables without assistance.
_____________________________________________________________
Patient's signature Date