Health History
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Chiropractic Case History/Patient Information

Date        Patient # Doctor

Name Social Security #

Address    City

State    Zip       Home Phone

E-mail Fax # Cell Phone

Age       Birth Date    Marital Status: M S W D     # of children?      Occupation

Employer

Employer's Address Office Phone

Spouse Occupation Employer

Name of Nearest Relative Address

Phone     How were you referred to our office?

Family Medical Doctor      Purpose of this appointment

Date symptoms appeared or accident happened:

Have you ever had the same or a similar condition? Yes   No 

If yes, when and describe:

Days lost from work

Date of last physical examination

What surgeries have you had? (Include dates)

Serious illnesses (include dates)

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

If yes, describe:

What medications or drugs are you taking?

Please check any and all insurance coverage that may be applicable in this case.

Major Medical      Worker's Compensation     Medicaid      Medicare   Auto Accident   Other

Name of Primary Insurance Company

Name of Secondary Insurance Company (if any)

AUTHORIZATION AND RELEASE: I authorize payment of insurance benefits directly to the chiropractor or chiropractic office. I authorize the doctor to release all information necessary to communicate with personal physicians and other healthcare providers and payors and to secure the payment of benefits. I understand that I am responsible for all costs of chiropractic care, regardless of insurance coverage. I also understand that if I suspend or terminate my schedule of care as determined by my treating doctor, any fees for professional services will be immediately due and payable. I understand that interest is charged on overdue accounts at the annual rate of 16%.

 

Patient's Signature     Date

Guardian's Signature Authorizing Care    Date

 

1. What is your major symptom?

2. If this is a recurrence, when was the first time you noticed this problem?

How did it originally occur?

Has it become worse recently? Yes    No     Same      Better    Gradually Worse

If yes, when and how?

3. How frequent is the condition? Constant     Daily      Intermittent     Night Only

How long does it last? All Day     Few Hours      Minutes

4. Are there any other conditions or symptoms that may be related to your major symptom?

Yes  No  If yes, describe

Are there other unrelated health problems? Yes      No  If yes, describe

5. Describe the pain: Sharp    Dull    Numbness      Tingling    Aching    Burning      Stabbing

Other

6. Is there anything you can do to relieve the problem? Yes No

If yes, describe

If no, what have you tried to do that has not helped?

7. What makes the problem worse? Standing     Sitting      Lying      Bending     Lifting      Twisting

Other

8. Have you had any broken bones? Yes     No  If yes, please list and give dates:

9. List any major accidents you have had other than those that might be mentioned above:

10. To your knowledge, have you had any diseases, major illnesses or injuries not indicated on this

form either in the past or the present? Yes     No      If yes, please explain:

11. WOMEN ONLY: Are you pregnant or is there any possibility you may be pregnant? Yes      No     Uncertain

12. Remarks:

 

Doctor’s Signature Date

 

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