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Please complete this form using your keyboard, then print it using the print function of your browser. You can then sign the form and bring it with you to your first appointment. ** This form will not be submitted via the Internet, so security is not an issue. 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 Race* Marital: M S W D # of children? Occupation Employer Office Phone Employer's Addres 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 wor 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 Compan 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 Are there other unrelated health problems? Yes No If yes, describe 5. Describe the pain:
Sharp
Dull
Numbness
Tingling
Aching
Burning
Stabbing 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 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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