Chiropratic Case History Form printable pdf download

Chiropractic Case History

Name _________________________________ Sex M F Date______________________

Address _________________________________________ State_________ Zip________

H. Phone _________________W. Phone______________ Date of Birth ____________Age_____

Referred by __________________________ Social Security _________________

Occupation ___________________________ Employer_________________________________________

Have you ever received Chiropractic Care? Yes__ No__ If yes, when?______________________________

. Primary reasons for seeking chiropractic care:

Primary reason: _______________________________________________________________________________________

Secondary reason: _____________________________________________________________________________________

Other reasons: ________________________________________________________________________________________

. Chief Complaint: ____________________________________________________________________________________

Location of Complaint: _________________________________________________________________________________

What was the initial cause of this complaint? ________________________________________________________________

When did this complaint begin? __________________________________________________________________________

Are you presently under a doctor’s care for this complaint? Y/N Doctors name:_____________________________________

Please circle the Quality of the complaint/pain: dull aching sharp shooting burning throbbing deep nagging other __________

Does this complaint/pain radiate or travel (shoot) to other areas of your body? Y/N Where? ___________________________

Do you have any numbness or tingling in your body? Where? __________________________________________________

Grade Intensity/Severity (0 No complaint/pain) 0 1 2 3 4 5 6 7 8 9 10 (10 Worst possible pain/complaint imaginable)

How frequent is complaint present. How long does it last? _____________________________________________________

Does anything aggravate the complaint? ___________________________________________________________________

Does anything make the complaint better? __________________________________________________________________

Does this complaint interfere with: work, home life, activities or sleep? Y/N _______________________________________

. Previous interventions: treatments, medications, surgery, or care you’ve sought for your complaint

____________________________________________________________________________________________________

. Past Health History:

A. Previous illnesses you’ve had in your life: ________________________________________________________________

B. Previous injury or trauma:_____________________________________________________________________________

Have you ever broken any bones? Which? __________________________________________________________________

C. Allergies __________________________________________________________________________________________

D. Medications: _______________________________________________________________________________________

Condition/s you are taking medications for: _________________________________________________________________

F. Surgeries and dates: _________________________________________________________________________________

G. Pregnancies, Date of Delivery & Outcomes _______________________________________________________________

____________________________________________________________________________________________________

H. Date of the beginning of your last menstrual period?______________ Any menstrual problems?_____________________

. Family Health History:

Associated health problems of relatives: ____________________________________________________________________

Deaths in immediate family: _____________________________________________________________________________

Cause of parents or siblings death & age at death _____________________________________________________________

. Social and Occupational History: _______________________________________________________________________

A. Level of Education: _________________________________________________________________________________

B. Job description: _____________________________________________________________________________________

C. Recreational activities: _______________________________________________________________________________

D. Do you take vitamins or supplements? Type and how often.__________________________________________________

E. Smoking and alcohol use. How often.____________________________________________________________________

On a scale of 1 – 10. How committed are you to resolving this complaint? ____

Are there any other health concerns you would like to address? _________________________________________________

I have read the above information and certify it to be true and correct to the best of my knowledge, and hereby authorize this

office to provide me/child with chiropractic care, in accordance with this state’s statutes.

Parent or Guardian Signature _______________________________________ Date _____________

Doctors Signature ________________________________________________ Date _____________

Chiropratic Case History Form

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