Chiropractic Case History

Name

Sex

Male Female

Date

Address

State

Zip code

Home phone

Work Phone

Date of Birth

Age

Referred By

Social Security #

Occupation

Employer

Have you ever received chiropractic care?

Yes No

If Yes, when?

Primary reason for seeking chiropractic care:

Primary Reason:

Secondary Reason:

Other factors contributing to primary and secondary reasons:

Chief complaint:

Location of complaint:

Complaint began when and how?

Please indicate the QUALITY of the complaint/pain:

dull aching sharp shooting burning throbbing deep nagging other

Does this complaint/pain radiate or travel (shoot) to any areas of your body? Where?

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

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

Does anything aggravate the complaint?

Does anything make the complaint better?

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

Please explain

Past Health History:

Previous illnesses you've had in your life:

Previous injury or trauma:

Have you ever broken any bones? Which?

Allergies

List all medications and reasons for taking:

Please list all surgeries - date and type

Females - pregnancy/date of delivery and outcome

When was the date of the beginning of your last mentrual period?

Family Health History

Associated health problems of relatives:

Deaths in immediate family - Please list cause of parents or sibling deaths and age at time of death:

Social and Occupational History

Level of Education

High school Some college College graduate Post graduate studies

Job description:

Work schedule:

Recreational activities:

Lifestyle (hobbies, level of exercise, alcohol, tobacco, drug use, diet):