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Chiropractic Case History/Patient Information

Date      

Name

Address    City   State   Zip

Sex: M F    Age       Birth Date   Marital: Married Single Widowed Divorced

Social Security # Occupation

Employer Office Phone

Employer's Address  

Spouse   Birthdate       Social Security #

Occupation    Employer

Whom may we thank for referring you to our office?

PHONE NUMBERS

Home Work

Best time & place to reach you

E-mail Fax # Cell Phone

In case of Emergency, Contact: Name Relationship

Home Phone       Work Phone

Doctor’s Signature Date

INSURANCE

Who is responsible for this account?

Relationship to Patient

Insurance Co.

Group #

Is patient covered by additional insurance? YES    NO

Subscriber's Name

Birthdate      SS#

Relationship to Patient

Insurance Co.

Group #

ASSIGNMENT AND RELEASE

I, the undersigned certify that I (or my dependent) have insurance coverage with and assign directly to Dr. all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

              

Responsible Party Signature                                                                  Date

Accident Information

Is condition due to an accident? YES   NO Date:

Type of accident? AUTO     WORK    HOME      OTHER

To whom have you made a report of your accident? AUTO INSURANCE       EMPLOYER     WORKER COMP   OTHER

Attorney Name (if applicable)

Patient Condition

Reason for Visit

When did your symptoms appear?

Is this condition getting progressively worse? YES   NO     UNKNOWN

Mark an "X" on the picture where you continue to have pain, numbness, or tingling.

wpe1C.jpg (78006 bytes)

Rate the severity of your pain on a scale from 1 (least pain) to 10 (severe pain)

Type of pain (circle): SHARP   DULL   THROBBING    NUMBNESS    ACHING        SHOOTING   BURNING TINGLING     CRAMPS     STIFFNESS      SWELLING     OTHER

How often do you have this pain?

Is it constant or does it come and go?

Does it interfere with your: WORK    SLEEP     DAILY ROUTINE    RECREATION

Activities or movements that are painful to perform: SITTING    STANDING     WALKING    BENDING    LYING DOWN

HEALTH HISTORY

What treatment have you already received for your condition? MEDICATIONS SURGERY  PHYSICAL THERAPY

CHIROPRACTIC SERVICES       NONE          OTHER

Name and address of other doctor(s) who have treated you for this condition

Date of Last:

Physical Exam

Spinal X-ray

Blood Test

Spinal Exam

Chest X-Ray

Urine Test

Dental X-Ray

MRI, CT-Scan, Bone Scan

"Yes" or "No" to indicate if you have had any of the following:

AIDS/HIV

 YES NO

Emphysema

 YES NO Miscarriage YES NO

Scarlet Fever

YES NO    

Alcoholism

 YES NO

Epilepsy

YES NO

Mononucleosis

YES NO

Stroke

 YES NO    

Allergy Shots

 YES NO

Fractures

YES NO

Multiple Sclerosis

 YES NO

Suicide Attempt

YES NO    

Anemia

YES NO

Glaucoma

 YES NO

Mumps

 YES NO

Thyroid Problem

 YES NO    

Anorexia

 YES NO

Goiter 

YES NO

Osteoporosis

 YES NO Tonsillitis YES NO    

Appendicitis

 YES NO

Gonorrhea

YES NO

Pacemaker

 YES NO

Tuberculosis

 YES NO    

Arthritis

 YES NO

Gout

YES NO

Parkinson's Disease

 YES NO

Tumors, Growths

 YES NO    

Asthma

 YES NO

Heart Disease

 YES NO

Pinched Nerve

 YES NO

Typhoid Fever

 YES NO    
Bleeding Disorders YES NO Hepatitis YES NO Pneumonia YES NO Ulcers YES NO    
Breast Lump YES NO Hernia YES NO Polio YES NO Vaginal Infections YES NO    
Bronchitis YES NO Herniated Disk YES NO Prostate Problem YES NO Venereal Disease YES NO    
Bulimia YES NO Herpes YES NO Prosthesis YES NO Whooping Cough YES NO    
Cancer YES NO High Cholesterol YES NO Psychiatric Care YES NO Headaches YES NO    
Cataracts YES NO Kidney Disease YES NO Rheumatoid Arthritis YES NO        
Chemical Dependency YES NO Liver Disease YES NO YES NO        
   
Chicken Pox YES NO Measles YES NO Rheumatic Fever YES NO        
Diabetes YES NO Migraine YES NO          

EXERCISE

WORK ACTIVITY

HABITS

NONE

SITTING

SMOKING    Packs/Day

MODERATE

STANDING

ALCOHOL   Drinks/Week

DAILY

LIGHT LABOR

COFFEE/CAFFEINE DRINKS Cups/Day  

HEAVY

HEAVY LABOR

HIGH STRESS LEVEL   Reason

Are you pregnant? YES    NO          Due Date:

Injuries/Surgeries

Description

Falls

Head Injuries

Broken Bones

Dislocations

Surgeries

MEDICATIONS

ALLERGIES

VITAMINS/HERBS/MINERALS

Pharmacy Name

Pharmacy Phone