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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   Birth Date       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

 

HEALTH HISTORY

What treatment have you already received for your condition? (circle) 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_________________________________________

Circle "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

Breat 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

Cataracts

YES    NO

Kidney Disease

YES    NO

Rheumatoid

 YES NO

Chemical Dependency

 YES     NO

Liver Disease

YES    NO

Arthritis

YES NO

Chicken Pox

YES    NO

Measles

YES    NO

Rheumatic Fever

YES NO

Diabetes

YES    NO

Migraine

 YES     NO

Headaches

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

______________________________

_____________________________

___________________________________

Patient Condition

Reason for Visit__________________________________________________________________

When did your symptoms appear?___________________________________________________

Is this condition getting progressively worse? (circle) 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 (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 (circle): WORK SLEEP DAILY ROUTINE RECREATION

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

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? (circle) AUTO INSURNACE EMPLOYER WORKER COMP OTHER

Attorney Name (if applicable)_____________________________

____________________________________________________

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

Accidental Injury Form

Name Date

Date of accident Time Location of accident

Auto Injury

Were you: Driver     Passenger     Pedestrian

Were you struck from: Behind      Right side      Left side      Front      Parked

Did your car strike the others involved? Yes     No      Undetermined

Did the other car strike yours? Yes     No      Undetermined

As a result of the accident, were traffic citations issued to you? Yes     No  

On-the-Job Injury

How did the injury occur?

Did you report the injury to your foreman or employer: Yes  No

Employer: Address:

Other

Describe the circumstances of the accident (Be Specific)

****************************************************************

CHECK SYMPTOMS YOU HAVE NOTIED SINCE THE ACCIDENT

Headache Sleeping Problems Lights Bother Eyes Diarrhea Neck Pain Head Too Heavy   Loss of Memory Feet Cold Neck Stiff Pins & Needles in Arms Ears Ringing Hands Cold Dizziness Arms Face Flushed  Stomach Upset Back Pain Pins & Needles in Legs Buzzing in Ears Constipation           Nervousness Numbness in Fingers Loss of Balance  Cold Sweats Tension Numbness in Toes Fainting  Fever  Irritability  Shortness of Breath  Loss of Smell   Chest Pain   Fatigue   Loss of Taste Other 

 

Did you require post-accident hospitalization? Yes  No

Have you lost any days of work? Yes    No If Yes, through

 

INSURANCE INFORMATION

Your Insurance Company Address

Other Party's Name

Address

Other Party's Ins. Co. Address

Have you been contacted by an insurance adjuster regarding this claim Yes No If yes, name of adjuster's company

Do you have an attorney that has advised you in this case: Yes No

If yes, attorney's Name Address

Signature Accidental Injury Form

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