Confidential Patient Case Info

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					                                        Confidential Patient Case Info.

 In order to serve you better, please print the following information. Please refer to our receptionist for
            assistance if you have any questions. The doctor will see you shortly. Thank you.

Nmne:                                                           _ Home Phone:
Address:                                                City:                         State:         Zip:        _

Age:          Birth Date:
                            -------------- Marital Status: M          S    D      W   N° of Children:
Email Address:                                                   _   Referred by:                                _

Employer:                                                            Occupation:                                _

Office Phone:                             Cell Phone:                                    SS N°:
                ------------------                      -------------------                       ------------
Do you have Insurance?       DYes       D      No

Do you have Medicare?        DYes       DNo

Name of Spouce or Parent/Guardian:                                                    Birth Date:                    _

Occupation:                                         Contact Number:                                                  _

Describe the reason why you are here today:                                                                     _

Is your Condition Due to an Accident?      DYes          D      No

Type of Accident:      0 Auto 0 Work/Job 0 Home                            D       Others:                          _

I (We) agree to pay for the services rendered to the above mentioned patient as the charge is incurred. I
understand that, this office does not perform health insurance billing. I understand that if I am a Medicare
patient, I will pay in full for services rendered to me, whether the service is covered or not covered. And I
will receive refund(s) from Medicare for the services that is covered. I also understand that if! terminate or
suspend my care and treatment, any fees for professional services rendered me will be immediately due
and payable.

Patient Signature:                                           _ Date:
Guardian's Signature (for minors):                                        Date:                             _
**NewPatientsnote** Paymentin full is due at the end of each appointment. If for any reasonthe requestcannot
be met arrangementsmust be made in advance.

Ebenezer Upper Cervical Chiropractic.    300 N Pottstown PK, Suite 280, Exton, PA 19341 .484-879-6053
                                            Patient Health History Info.

Name:                                                                  Dme:                              _

List All Current Health Problems:

List Any Other Doctors Seen, Treatments And Results Obtained:                                        _

Your Current Physician( s)/Therapist( s):                                                                    _

List All Surgeries Performed And Their Dates:                                                            _

List Any Medication You Are Taking:                                                                      _

List Any Traumas And Their Dates:                                                                        _

Please ChecdThe       Condition You Have Or Have Had:
   o   AIDS                      0 Diabetes                       o    Polio
   o   Anemia                    0 Epilepsy                       o    Rheumatic Fever
   o   Arthritis                 0 Fibromyalgia                   o    Rheumatoid Arthritis
   o   Cancer                    0 Hypoglycemia                   o    Tuberculosis
   o   Chronic Fatigue           0 Multiple Sclerosis             o    Venereal Disease
   o   Depression                0 Parkinson's Disease
Please Check   d'All Present   Symptoms:
   o    General Swelling                    o   Double Vision             o   Inability to form words
   o    Swelling in legs                    o   Loss of coordination      o   Burning sensations
   o    Swelling in face                    o   Loss of memory            o   Blindness
   o    Swelling around eyes                o   Ringing in ears           o   Previous head injury
   o    Chest pain                          o   Heart Attack              o   Previous neck injury
   o    Pounding heart beat                 o   High blood pressure       o   Taking birth control
   o    Rapid heart beat                    o   Muscle weakness           o   Family history of stroke
   o    Irregular heart beat                o   Dizziness                 o   Blood vessel disease
   o    Blue or purple nail beds

EbenezerUpper Cervical Chiropractic.   300 N Pottstown PK, Suite 280, Exton, PA19341 .484-879-6053
                                                  Patient Health Review Info.

Please Check    dAll Present Symptoms:
Eyes                                   Respiratory                           Social History
o Blurred vision                       0    Shortness of breath              o Smoking
o Double vision                        o    Dry cough                        o Other tabacco use
o Eye fatigue                          0    Coughing up blood                o Alcohol use
o Excessive tearing                    0    Wheezing                         o Drink coffee or tea
o Lack of tearing                      o    Productive cough
o Sensitivity to light                                                       o Nervousness
o Excessive itching                    Gastrointestinal                      o Irritability
o Pain in eyeballs                     o Poor appetite                       o Fatigue
o Short sightedness                    o Difficulty swallowing               o Depression
o Long sightedness                     o Indigestion                         o Panic attacks
                                       o Nausea & vomitting                  o Problems sleeping
Ears                                   o Abdominal pain                      o Generally feel rundown
o Loss of hearing                      o Change in bowel habits
o Pain in ears                         o Diarrhea                            Diet is
o Ringing in ears                      0 Constipation                        0    Balanced
o Discharge from ears                  o Irritable bowel                     0    Not balanced
o Pressure in ears                     o Hemrroids
o Vertigo                                                                    Rest is
                                       Genitourinary                         0 Sufficient
Nose & Sinuses                         o Frequent urination                  0 Not sufficient
 o Nose obstruction                    o Insufficient urination
 o Nose bleed                          o Bed wetting                         Recreation is
 o Frequent colds                      o Frequent urination at night         0 Sufficient
 o Sinusitis                           o Intense desire to urinate           0 Not sufficient
 o Loss of smell                       o Difficulty urinating
 o Allergies                           o Lack of control                     Family stress is
                                       o Pain with urination                 0 Severe
Mouth & Throat                         o Dribbling                           0 High
 o Pain in throat                      o Bloody urine                        0 Moderate
 o Bleeding gums                       0    Cloudy urine                     0 Minimal
 o Difficulty swallowing                                                     0 None
 o Dentures                            Venereal Disease
 o     Abscessed teeth                 0    Syphilis                         My job stress is
                                       o    Gonorrhea                        0    Severe
Skin, Hair & Nails                     o    Chlamydia                        0    Moderate
0      Eczema                                                                0    Minimal
0      Itchy skin                      Women Only                            0   None
0      Rough, scaly skin               o Painful periods
0      Dry skin                        o Spotting
0      Oily skin                       o Pre-mentrual symptoms
0      Bruise easily                   o Irregular periods
0      Baldness                        o Lumps in breast
0      Paper thin skin                 o Vaginal discharge
0      Nail bitting                     # of pregnancies
                                        # of deliveries

EbenezerUpper Cervical Chiropractic.   300 N Pottstown PK, Suite 280, Exton, PA19341 .484-879-6053
                                         Patient MusculoSkeletal              System Info.

Please Check ~     All Present Symptoms:

Head                                            Arms & Hands
   CJ Frequent   headaches                         o Pain in upper arm
   o   Severe headaches                            o Pain in forearm
   o   Head feels heavy                            o Pain in wrists
   o   Vertigo                                     o Pain in fingers
   o   Dizziness                                   o Pins & needles
   o   Light headedness                            o Numbness in arms or band or fingers
   o   Loss of taste                               o Fingers go to sleep
   o   Loss of smell                               o Cold hands
   o   Loss of hearing                             o Swollen fingers
   o   Loss of balance                             o Loss of grip strengtb
   o Twitching     in face                      Mid Back
   o Excruciating pain in face                      o Mid-back pain
   o Dropping eyes, mouth                           o Pain between shoulder        blades
                                                    o Sharp stabbing pain
Neck                                                o Dull    ache
   [] Pain in neck                                  []   Pain from front to back
   o  Pain with movement                            o    Pain over kidneys
   o  Swelling in neck                              o    Muscle spasms
   o  Stiffness in neck
   o  Pinched nerve in neck                     Lower Back
   [] Neck feels out of place                       [] Lower back pain
   o  Muscle spasm in neck                          o Lower   back feels tight
   o  Grinding sounds in neck                       o  Muscle spasms
   o  Popping sounds in neck                        o  Dull ache
   o  Limited neck movement
                                                Hips, Legs & Feet
Shoulders                                           o Pain in the buttocks
   o Pain in shoulders                              o Pain in hips
   o Pain across shoulders                          o Pain down the legs
   [] Can't raise arm above shoulders               [] Knee Pain
   [] Above bead                                    [] Legs cramps
   o  Limited movement in shoulders                 o  Pins & needles in legs
                                                    o  Numbness in legs
                                                    o  Numbness in toes
                                                    o  Numbness in sole
                                                    o  Cold feet
                                                    o  Swollen ankles
                                                    [] Swollen feet

Ebenezer Upper Cervical Chiropractic.   300 N Pottstown PK, Suite 280, Exton, PA 19341 .484-879-6053

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