Chiropractic Case History/patient Information Form

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Chiropractic Case History/Patient Information
Date:__________________
Patient #___________
Doctor:___________________
Name:__________________________
Social Security #__________________Home Phone: _______________
Address:____________________________________City:___________________ State:______ Zip:___________
E-mail address:____________________________Fax # __________________ Cell Phone:__________________
Age:_______ Birth Date:___________ Race:______ Marital: M S W D
Occupation:_________________________ Employer:________________________________________________
Employer's Address:__________________________________ Office Phone:_____________________________
Spouse:___________________ Occupation:________________ Employer:_______________________________
How many children?____________Names and Ages of Children:________________________________________
___________________________________________________________________________________________
Name of Nearest Relative:________________________ Address:______________________Phone:___________
How were you referred to our office?______________________________________________________________
Family Medical Doctor:_________________________________________________________________________
When doctors work together it benefits you. May we have your permission to update your medical doctor regarding
your care at this office?___________
HISTORY OF PRESENT ILLNESS:
Chief Complaint: Purpose of this appointment:_______________________________________________
Date symptoms appeared or accident happened:_________________________________________
Is this due to: Auto___ Work____ Other________________________________________________
□ Yes □ No If yes, when and describe:______________
Have you ever had the same or a similar condition?
___________________________________________________________________________________________
Days lost from work:_________________ Date of last physical examination:_________________________
PAST MEDICAL HISTORY
Have you ever been diagnosed as having or have suffered from? (Place a check mark by conditions that apply to
you)
__Broken or Fractured Bones
__Osteoarthritis
__Eating Disorder
__Circulatory Problems
__Epilepsy
__Alcoholism
__Rheumatoid Arthritis
__Pace Maker
__Drug Addiction
__Seizures/Convulsions
__Strokes
__HIV Positive
__A Congenital Disease
__Cancer
__Gall Bladder
__Excessive Bleeding
__Ruptures
__Depression
__High/Low Blood Pressure
__Coughing Blood
__Ulcers
Do you have a history of stroke or hypertension?_____________________________________________
Have you had any major illnesses, injuries, falls, auto accidents or surgeries? Women, please include information
about childbirth (include dates): _________________________________________________________________
___________________________________________________________________________________________
□ Yes □ No
Have you been treated for any health condition by a physician in the last year?
If yes, describe:_______________________________________________________________________________
What medications or drugs are you taking?_________________________________________________________
___________________________________________________________________________________________
Do you have any allergies to any medications? □ Yes
□ No
If yes, describe:_______________________________________________________________________________

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