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Chiropractic Case History/Patient Information Date: . Name: Social Security # Address: City: (If Different than above.) Mailing Address:. City E-mail address: Age: Home Phone: ( Race: Occupation: . State:______ Zip: . State:______ Zip: Fax # Birth Date: ) . Cell Phone: . Marital: M S W D How many children? . Employer: Employer's Address: Spouse: Occupation: . Office Phone: . Employer: . Name of Nearest Relative Not Living With You : . Address: Phone: ( ) . How were you referred to our office? . Family Medical Doctor: City . When doctors work together it benefits you. May we have your permission to update your medical doctor regarding your care at this office? YES NO HISTORY OF PRESENT ILLNESS: Chief Complaint: Purpose of this appointment: . Date symptoms appeared or accident happened: . How frequent is the condition? Constant Daily Is there anything you can do to relieve the problem? Yes Intermittent No Night Only . If yes, describe . . If no, what have you tried to do that has not helped? What makes the problem worse? Standing Lifting Twisting Is this due to: Auto Sitting . Lying Other Work Bending . . Other Have you ever had the same or a similar condition? YES NO If yes, when and describe: . . .. Other Doctors seen for this condition Days lost from work: . Date of last physical examination: . 1 of 4 PAST MEDICAL HISTORY Have you had or do you now have any of the following symptoms that are or have been of significant distress to you? Please indicate with the letter N if you have these conditions now or P if you have had these conditions previously. N = Now P = Previously Broken or fractured bones ________ Osteoarthritis ________ Circulatory Problems ________ A Congenital Disease ________ Depression ________ Ulcers ________ Alcoholism ________ Drug Addiction ________ Eating Disorders ________ Coughing Blood ________ Headaches_________ Frequency ________ Neck Pain ________ Stiff Neck ________ Sleeping Problems ________ Back Pain ________ Nervousness ________ Tension ________ Irritability ________ Chest Pains/Tightness ________ Dizziness ________ Shoulder/Neck/Arm Pain ________ Numbness in Fingers ________ Numbness in Toes ________ High/low Blood Pressure ________ Difficulty Urinating ________ Weakness in Extremities ________ Breathing Problems ________ Fatigue ________ Lights Bother Eyes ________ Ears Ring ________ Rheumatoid Arthritis Seizures/ Convulsions Strokes Cancer Epilepsy Pace Maker HIV Positive Gall Bladder Ruptures Excessive Bleeding Loss of Balance Fainting Loss of Smell Loss of Taste Unusual Bowel Patterns Feet Cold Hands Cold Arthritis Muscle Spasms Frequent Colds Fever Sinus Problems Diabetes Indigestion Problems Joint Pain/Swelling Menstrual Difficulties Weight Loss/Gain Loss of Memory Buzzing in Ears __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ P= Previously N= Now Leave blank if none Do you have a history of stroke or hypertension? . Have you had any major illnesses, injuries, and falls, auto accidents or surgeries? Women, please include information about childbirth (include dates): . . Has a physician treated you for any health condition in the last year? YES NO If yes, describe: . What medications or drugs are you taking? . . What vitamins/supplements are you taking? . . Do you have any allergies to any medications? YES NO If yes, describe: Do you have any allergies of any kind? YES . NO If yes, describe: . Please list any other health problems you have, no matter how insignificant they maybe: . 2 of 4 On the diagram mark the areas on your body where you feel your pain. Include all affected areas. Mark areas of radiation. If your pain radiates, draw an arrow from where it starts to where it stops. Please extend the arrow as far as the pain travels. Use the appropriate symbol (s) listed below. Ache ***** Numbness +++++ Pins & Needles ooooo Burning xxxxx Stabbing <<<<<< Throbbing ///////// SOCIAL HISTORY: Do you drink alcoholic beverages? If so, how much per week? Do you use any tobacco products? Do you smoke? Do you consume caffeine? . If so, packs per day: If so, how much per day: Do you exercise? . . If yes, what is the frequency and type of exercise? . What are your hobbies? . What are your biggest life stressors: FAMILY FINANCES WORK OTHER . What percentage of time during the day (at home or at your job away from home) do you spend: Lifting sitting bending working at a computer . FAMILY HISTORY: Father: living deceased Current age if still living: Cause of death and age at death if deceased: . Health problems or Illnesses Mother: living deceased . Current age if still living: Cause of death and age at death if deceased: . Health problems or Illnesses Paternal Grandfather: living . deceased Current age if still living: Cause of death and age at death if deceased: . Health problems or Illnesses . Paternal Grandmother: living deceased Current age if still living: Cause of death and age at death if deceased: . Health problems or Illnesses . Maternal Grandfather: living deceased Current age if still living: Cause of death and age at death if deceased: . Health problems or Illnesses . Maternal Grandmother: living deceased Current age if still living: Cause of death and age at death if deceased: . Health problems or Illnesses . 3 of 4 FAMILY HISTORY cont.: Sibling: living deceased Current age if still living: Cause of death and age at death if deceased: . Health problems or Illnesses Sibling: living deceased . Current age if still living: Cause of death and age at death if deceased: . Health problems or Illnesses Sibling: living deceased . Current age if still living: Cause of death and age at death if deceased: . Health problems or Illnesses Sibling: living deceased . Current age if still living: Cause of death and age at death if deceased: . Health problems or Illnesses . Do you have any family members who suffer from the same condition you do? If so, please list: . Check if applicable to you: As an adopted child, little is known of birth parents or family. Insurance Information Please circle any and all insurance coverage that may be applicable in this case: Major Medical Worker's Compensation Medical Savings Account & Flex Plans 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. The patient understands and agrees to allow this chiropractic office to use their Patient Health Information for the purpose of treatment, payment, healthcare operations, and coordination of care. We want you to know how your Patient Health Information is going to be used in this office and your rights concerning those records. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information we encourage you to read the HIPAA NOTICE that is available to you at the front desk before signing this consent. If there is anyone you do not want to receive your medical records, please inform our office. Patient's Signature: Date: . Guardian's Signature Authorizing Care: Date: . 4 of 4