Chiropractic Case History Form printable pdf download

CASE HISTORY

Name _______________________________________Age _________Date __________

Address _______________________________________ City ________________ State_____ Zip________

Phone (Home) __________________ Date of Birth ________________ Sex: M F Marital Status: S M D W

Social Security # _____________________Driver’s License #_____________________________________

Occupation Employer _______________________________________ Phone (Work)__________________

Insurance Company_________________________________________ Phone________________________

Insured’s Name _________________________________ Insured’s Date of Birth _____________________

Insured’s ID. # or S.S. # __________________________________

Spouse’s Name _______________________Spouse’s Occupation _________________________________

Spouse’s Employer __________________________Spouse’s Phone (Work)__________________________

Spouse’s Insurance Co. ______________________________________ Phone________________________

Spouse’s Social Security # ________________________________

Present condition due to an injury? __ Yes __ No __ On the Job __ Auto Accident __ Other _____________

Has the accident been reported? __ Yes __ No __ To Employer __ Auto Carrier __ Other ________________

HEALTH REPORT:

Reason for seeking care: ___________________________________________________________________

List any other doctors seen for this: __________________________________________________________

List any diagnosis and type of treatment: _________________________________________________

Have you had similar accidents or injuries before? __ Yes __ No If yes, explain: ______________________

List the names of any relatives that have or have had a similar problem: _____________________________

Have you or any relative received chiropractic treatment previously? __ Yes __ No

If yes, explain: ______________________________________________________

Have you been treated for any health condition by a physician in the last year? __ Yes __ No

If yes, explain: ______________________________________________________

Are you currently taking medication? __ Yes __ No list medications: _______________________________

_______________________________________________________________________________________

Have you taken medication in the past? __ Yes __ No list medications _______________________________

List conditions you are taking medications for: ______________________________________________________

List the approximate dates of any surgery or treated conditions:__________________________________________

_____________________________________________________________________________________________

Family History: Health conditions, age of death and cause of death.

Father: ______________________________________________________________________________________

Mother: _____________________________________________________________________________________

Brother/s & Sister/s: ___________________________________________________________________________

Do you smoke Y/N ____ Alcohol Y/N __Daily __Weekly __Social Occasions Caffeinated drinks per day ____

Do you take Vitamins/Supplements Y/N If yes, type and how often _____________________________________

Please circle degree of pain, 0 none, 10 severe pain.

0 1 2 3 4 5 6 7 8 9 10

Using the symbols below, mark on the pictures where you feel

pain.

Numbness

= = =

Dull Ache

OOO

Burning

XXX

Sharp/Stabbing

/ / /

Pins, Needles

+ + +

Other ______

^ ^ ^

What activities aggravate your condition/pain?___________

What activities lessen your condition/pain?______________

Is this condition worse during certain times of the day? Y/N

Is this condition interfering with

Work?__________

Sleep?__________Routine?_______Other?____________

Is this condition progressively getting worse?___________

________________________________________________

Chiropractic Case History Form

Related Articles

Related forms

Related Categories