CASE NO. ______________

Please fill out the following form in as much detail as possible.

Please print
Date ___________________

Name __________________________________________________________________

Address ________________________________________________________________

City ___________________________________ State _____________ Zip ________

Home Phone ____________________________ Office Phone __________________

E-mail Address ___________________________________________________________
Age _______ Date of Birth __________ Occupation ____________ Sex (M) (F)

Weight ______________ Referred by _______________________________________

Employer __________________________ Address ____________________________

Married ___ S ___ W ___ D ___ Children____ Name of Spouse __________________

Is any other member of your family being treated in this office? ____________________

Have you ever had chiropractic care before? ____________________________________

For what problem? ________________________________________________________

Were the results satisfactory? Yes______ No_______ N/A_______

Major complaints and symptoms — please be as specific as you can.

Ask the doctor or nurse for help if you need assistance in filling out this section.

________________________________________________________________________
_________________________________________________________________________

_________________________________________________________________________

How do you believe your problem (pain) began? ________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
When did you first notice this problem/pain? ___________________________________

Have you lost any work? ____________ Day and date you last worked _____________

Have you ever had this condition before or a similar condition? ____________________

When? __________________________________________________________________

What positions or activities aggravate your condition? ____________________________

What positions or activities relieve your condition? ______________________________

Have you ever been treated by a Medical Physician for this ailment?_________________

Where? _________________________________________________________________

Describe the type of treatment ______________________________________________

Diagnosis of previous physician _____________________________________________

Length of time under care_______________________ Results ____________________

Family physician’s name ___________________________________________________
Please send a report to my family physician. Yes____ No ____

Will this case be covered by any insurance company? Major Medical _____ Auto ______

Blue Cross/Blue Shield ____ Workers’ Compensation ____ Medicare _____ Other _____

Have you ever been in any accidents, auto, fall down stairs, fall from ladder, etc.
(even as a child)?_______________ When? ____________________________________

Are you allergic to anything you are aware of? __________________________________

Are you presently taking any medication, herbs, or over the counter products
(aspirin included)? Yes_______ No________
If yes, name them _________________________________________________________

Have you ever broken any bones? (fractures) ___________ Any dislocations? ________

What operations have you had?

____________________Year _________________
____________________Year _________________
____________________Year _________________

Have you ever had any cosmetic surgery, breast implants, etc.? _______Year _________

Have you had any surgery to replace hip, knee, etc.? ___________Year _____________
Give dates you have had any of the following? (if exact date is unknown, give approximate)

Blood tests ________________________ Urinalysis _____________________________

MRI _______________ CT Scan ________________ Ultrasound __________________

Radiation Treatment ___________________ X-Ray examination __________________

Other special treatment ____________________________________________________

At what hospital or office were these tests taken ________________________________

Name of doctor who ordered tests ____________________________________________

Date of last menstrual period ________________________________________________

Do you have any reason to believe that you may be pregnant? Yes ______ No_______

Do you have any health problems not listed above? ______________________________

Do you faint easily? _______________________________________________________

Do you take vitamins? Yes______ No ______ If yes, please list them _______________

Do you exercise regularly? Yes ________ No ________ What kind of exercise? _______

________________________________________________________________________

Habits: (please check)

Cigarettes ________ Quantity ___________ Coffee? ________ Quantity ____________

Alcohol? ________ Quantity ___________ Tea? ________ Quantity _______________

Hobbies ________________________________________________________________

Have you been treated for any health condition by a physician in the past year? _______
If yes, what condition? _____________________________________________________

Have you lost or gained weight in the past year? ________________________________

Use this space for any additional information you may wish to discuss _____________
________________________________________________________________________
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Have you had or do you now have any of the following symptoms which are or have been of significant distress to you? Please indicate with the letter N if you have these conditions now (within the past 12 months) or P if you ever had these conditions in the past.

Now= N, Past= P
N P N P
Headaches____ Frequency ____ ____ Loss of Balance ____ ____
Neck Pain ____ ____ Fainting ____ ____
Stiff Neck ____ ____ Loss of Smell ____ ____
Sleeping Problems ____ ____ Loss of Taste ____ ____
Back Pain ____ ____ Diarrhea ____ ____
Nervousness ____ ____ Feet Cold ____ ____
Tension ____ ____ Hands Cold ____ ____
Irritability ____ ____ Arthritis ____ ____
Chest Pains ____ ____ Muscle Spasms ____ ____
Dizziness ____ ____ Frequent Colds ____ ____
Shoulder/Neck/Arm Pain ____ ____ Stomach Upset ____ ____
Pins & Needles in Arms ____ ____ Constipation ____ ____
Pins & Needles in Legs ____ ____ Cold Sweats ____ ____
Numbness in Fingers ____ ____ Fever ____ ____
Numbness in Toes ____ ____ Sinus Problems ____ ____
High Blood Pressure ____ ____ Diabetes ____ ____
Difficulty Urinating ____ ____ Hemorrhoids ____ ____
Allergies ____ ____ Leg Cramps ____ ____
Weakness in Arms ____ ____ Colitis ____ ____
Weakness in Legs ____ ____ Gall Bladder ____ ____
Shortness of Breath ____ ____ Indigestion ____ ____
Fatigue ____ ____ Belching ____ ____
Depression ____ ____ Vomiting ____ ____
Lights Bother Eye ____ ____ Shoulder Pain ____ ____
Loss of Memory ____ ____ Swelling Joints ____ ____
Ears Ring ____ ____ Knee Pain ____ ____
Face Flushed ____ ____ Hayfever ____ ____
Buzzing in Ears ____ ____ Menstrual Difficulties ____ ____

I understand and agree that health and accident insurance policies are an agreement between the insurance carrier and me, and that all services rendered me are charges directly to me, and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered me will be immediately due and payable.

PATIENT SIGNATURE __________________________________________________
SOCIAL SECURITY NUMBER ________________________ DATE ____________