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Chiropractic Case History/Patient Information
PATIENT INFORMATION
Date Patient
Address
City State Zip
Sex: Male Female Age Birthdate
Single Married Widowed Separated Divorced
Patient Social Security #
Occupation
Employer
Employer Address
Employer Phone
Spouse's Name
Birthdate Social Security #
Occupation
Spouse's Employer
Whom may we thank for referring you?
PHONE NUMBERS
Home Work Ext.
Best time and place to reach you
IN EVENT OF EMERGENCY
Name Relationship
Home Phone Work Phone
Doctor's Signature Date
INSURANCE INFO
Who is responsible for this account?
Relationship to Patient
Insurance Company
Group #
Is patient covered by additional insurance? Yes No
Subscriber's Name
Birthdate Social Security #
Relationship to Patient
Insurance Company
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
Relationship 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.
Rate the severity of your pain on a scale from 1 (least pain) to 10 (severe pain)
Type of pain: 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 your 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 | |
Place a mark on "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 Problems 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 |
Other:
|
| Cataracts Yes No | Kidney Disease Yes No | Rheumatoid Arthritis Yes No | |
| Chemical Dependency Yes No | Liver Disease Yes No | ||
| Chicken Pox Yes No | Measles Yes No |
Rheumatic Fever
Yes No |
|
| Diabetes Yes No | Migraine Headaches Yes No |
EXERCISE
None Moderate Daily Heavy
WORK ACTIVITY
Sitting Standing Light Labor Heavy Labor
HABITS
Smoking Packs/Day
Alcohol Drinks/Week
Coffee/Caffeine Drinks Cups/Day
High Stress Level Reason
Are you pregnant? Yes No Due Date
Injuries/Surgeries you have had Description Date
Falls
Head Injuries
Broken Bones
Dislocations
Surgeries
| MEDICATIONS | ALLERGIES | VITAMINS/HERBS/MINERALS |
| Pharmacy Name | ||
| Pharmacy Phone |
