Patient Case History

If you need any assistance completing this paperwork, just ask. It is our pleasure to help you.
We want your visit with us to be comfortable, helpful, and educational.

confidential health information

date

clinic id

1

PATIENT INFORMATION

last name

first name

m.i.

2

HEALTH COMPLAINTS

Are you here because you were injured while working, in a motor vehicle collision, or in another accident?

yes

no

What services interest you? (mark all that apply)

injury prevention

treatment for pain

patient education classes

balance and coordination training

spinal and body alignment

body composition counseling

range of motion, mobility, or flexibility therapy

strengthening and stamina exercise

nutritional and supplement counseling

other:

What is your primary complaint?

How long have you been experiencing this primary complaint?

How does the primary complaint feel?

dull/achy

cold

burning

tingling

numb

sharp

How often do you experience the primary complaint?

yearly

monthly

daily

weekly

constantly

Using the scale below, rate how your primary complaint affects your life. (mark only one box below)

pain that prevents working and all personal activity

pain that keeps me bed ridden

pain that causes thoughts of suicide

pain that prevents working at all

no pain or discomfort

slight discomfort

pain that does not affect my activity

pain that affects my daily activities

pain that limits my work schedule

pain that prevents performing my daily activities

10

9

8

7

6

4

5

3

2

1

If you have missed work because of your primary complaint, what was your last day of work?

What do you believe is causing your primary complaint?

List other health complaints (2-5) on the following lines.

4

2

5

3

Do you have any other condition other than what brings you here?
If YES, list it here:

no

yes

Please mark the areas of all
of your complaints on the
diagrams to the right.
Include any descriptors or
comments, concerning your
health complaints that were
not mentioned above.

N = numbness
T = tingling
P = pain
W = weakness

patient name

3

LIFESTYLES & HABITS

How many hours of television do you watch a day?

3-5

>5

< 1

1-3

Do you usually snack while watching television?

no

yes

How many hours per day do you use a computer at work or home?

< 1

3-5

1-3

>5

How many hours per day do you ride in a car or other vehicle?

< 1

3-5

>5

1-3

How often do you exercise?

daily

3x’s/week

2x’s/week

1x/week

I don’t exercise

How long do your exercise work outs last?

30 minutes

1 hour

>1 hour

NA

< 30 minutes

What are your exercise activities? (mark all that apply)

I don’t exercise

walking

swimming

weight lifting

stretching/flexibility

resistance bands

yoga/Pilates

running/treadmill/rowing/climbing

group exercise classes

other

Do you take a multi-vitamin?

If YES, what brand do you take?

yes

no

List any other nutritional supplements you are currently taking.

reason

supplement

reason

supplement

3.

1.

2.

4.

Have you ever used tobacco?

never

daily

monthly

yearly

weekly

How many servings of alcohol do you drink each week?

3-5

1-2

>5

0

How many servings of coffee do you drink each week?

3-5

1-2

0

>5

How many servings of soda do you drink each week?

0

3-5

>5

1-2

4

FAMILY HISTORY

Mark the following conditions as they pertain to your immediate family.     n=never     p=previously     c=currently

diabetes

heart problems

kidney problems

cancer

headaches

back pain

obesity

poor conditioning

father

brother

sister

mother

c

p

n

p

c

n

p

c

n

p

c

n

brother

sister

mother

father

c

p

c

n

p

c

n

n

p

c

n

p

brother

sister

mother

father

c

c

n

p

n

p

c

n

p

c

n

p

mother

father

brother

sister

n

p

c

n

n

p

c

p

n

p

c

c

sister

mother

father

brother

p

n

c

n

p

n

p

c

n

p

c

c

sister

brother

mother

father

c

n

p

n

p

c

n

p

n

c

p

c

mother

brother

father

sister

n

p

c

n

p

c

n

p

c

p

c

n

brother

sister

father

mother

p

c

c

n

p

p

c

n

n

n

p

c

5

CONDITIONS

Mark the following conditions as they currently pertain to you.

polio

rheumatic fever

tuberculosis

venereal infection

whiplash

whooping cough

low back pain

measles

mental disorder

mumps

pleurisy

pneumonia

epilepsy

goiter

heart disease

HIV positive

influenza

diabetes

alcoholism

anemia

appendicitis

arthritis

cancer

yes

no

yes

no

yes

yes

no

no

no

no

yes

yes

yes

no

yes

no

no

yes

yes

no

yes

no

no

yes

yes

yes

no

no

no

no

yes

yes

no

yes

yes

no

no

yes

no

yes

yes

no

yes

yes

no

no

patient name

6

INJURIES

List any auto collisions that you were involved in, either as the driver or passenger, below. Begin with the most recent.

type of collision

date of collision

type of treatment received

1.

2.

3.

List any job injuries that you experienced below. Begin with the most recent.

type of treatment received

date of job injury

type of job injury

1.

2.

3.

List any sports injuries that you experienced below. Begin with the most recent.

type of sports injury

date of sports injury

type of treatment received

1.

2.

3.

List any other injuries caused by falls or impacts. Begin with the most recent.

type of injury

date of injury

type of treatment received

1.

2.

3.

7

HOSPITAL / MEDICINE

Have you had breast implant surgery?

yes

no

Have you had knee or hip replacement surgery?

no

yes

Do you have a pacemaker?

yes

no

Do you have any other implantable medical devices in your body?

yes

no

Mark all of the following procedures as they pertain to you.

rectal surgery

sinus surgery

hernia surgery

thyroid surgery

stomach surgery

yes

no

vaccinations

tonsillectomy

gall bladder removal

back surgery

tubes in ears

appendectomy

female/male surgery

yes

no

yes

yes

no

no

no

no

yes

yes

no

yes

no

no

yes

no

yes

yes

no

no

yes

yes

List any prescription or over-the-counter medications you are currently taking.

medication

reason

medication

reason

1.

3.

2.

4.

Were you ever knocked unconscious?

Have you ever had a lapse of memory?

no

yes

no

yes

List any broken bones or dislocations that you had.

Have you ever had a spinal tap or spinal injection?

yes

no

patient name

8

SYSTEM REVIEW

Mark the following conditions that are currently a cause of significant concern for you.

General

chills

convulsions

depression

dizziness

consistent fainting

fever

loss of weight

headache

fatigue

loss of sleep

wheezing

weight gain

night sweats

nervousness

neuralgia

Gastro-Intestinal

diarrhea

hemorrhoids

jaundice

gall bladder problems

constipation

stomach pain

poor appetite

nausea

poor digestion

liver problems

vomiting blood

vomiting

rectal bleeding

Eye/Ear/Nose/Throat

asthma

crossed eyes

ear discharge

earache

deafness

frequent colds

hay fever

enlarged thyroid

ear noises

hoarseness

sinusitis

poor vision

pain in eyes

nasal obstruction

nose bleeds

tonsillitis

sore throat

Respiratory

difficulty breathing

spitting blood

spitting phlegm

chronic cough

chest pain

Muscles/Joints/Bones

foot problems

backache

pain bet. shoulders

stiff neck

painful tailbone

twitching

tremors

swollen joints

spinal curvature

weakness

Cardio-Vascular

high blood pressure

pain over heart

low blood pressure

heart trouble

ankle swelling

strokes

rapid heart

poor circulation

slow heart

Skin or Allergies

dryness

eczema

hives

itching

bruise easily

sensitive skin

Women

excessive flow

irregular cycle

painful periods

hot flashes

cramps

9

PREGNANCY

WOMEN ONLY

X-rays are contra-indicated during pregnancy.  This clinic does not knowingly x-ray women who are or may be pregnant regardless of stage or trimester of pregnancy.  If there is a chance that you may be pregnant let the doctor or assistant know right now.

On what date did your last period begin?

Are you pregnant?

yes

no

OFFICE USE ONLY
result of clinic pregnancy test:

Do you want to take a pregnancy test now?

yes

no

+     -

Mark the following situations as they pertain to you.

partner had a vasectomy

tubal ligation

complete or partial
hysterectomy

yes

no

yes

no

no

yes

less than 10 days since the start of my last period

taking birth control pills

no

yes

yes

no

I understand and agree to the following:
• A history, consultation, examination, and x-rays are conducted for 
  diagnostic and informational purposes and I am requesting these services
• It is my responsibility to complete the clinic’s forms accurately
• It is my responsibility to notify the doctor if any of my information has changed or 
   requires updating
• Original x-rays are the clinic’s property and copies of the original film(s) and 
   report(s) will be released to me upon written request

patient or guardian signature   

date

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