CONFIDENTIAL CASE HISTORYDate:______
Full Legal Name______SSN#______
Address ______City/State/Zip______
Phone (H)______(W)______(C)______Prefer H W C
Birth Date___/___/_____ Age ______Sex ______Marital Status S M W D Partner
Spouse’s Name______#Children ___ Ages______
Emergency Contact ______Phone ______
Your Employer ______Occupation______
Employers Address______City/State/Zip______
Email address______Referred by______
MEDICAL HISTORY (please be complete)
List any surgeries or hospital stays______
List current medications______
List auto accidents with dates______
List on the job injuries with dates______
List any current or past major medical conditions
List any health conditions that run in your family (cancer, diabetes, heart disease, etc)
Have you been under a physicians care this past year No__ Yes __ Why______
Have you had chiropractic care previously No__ Yes__ Why ______
Do you smoke No__ Yes__ How much______Are you pregnant No___ Yes___
Exercise Habits Never______Occasional______Frequently______
Check any of the following symptoms you have noticed:
Present/Past Present/PastPresent/Past
___/___ Headache ___/___ Low Back Pain ___/___Sensitive to light or sound
___/___ Dizziness or light headed ___/___ Leg/foot numb/tingling ___/___Visual or hearing disturbance
___/___ Jaw pain, clicking/locking___/___ Leg/foot fatigue or weakness___/___ Memory loss/problems
___/___ Pain or difficulty swallowing___/___ Leg pain with walking ___/___ Irritability/Depression
___/___ Neck pain or stiffness___/___Abdominal pain ___/___ Fatigue or energy loss
___/___ Shoulder pain ___/___ Nausea or vomiting ___/___ Fainting or convulsions
___/___ Mid back pain___/___ Diarrhea or constipation ___/___ Trouble with balance
___/___Chest pain or cough___/___ Blood in urine/stool ___/___ Sleep problems
___/___Trouble breathing___/___ Difficulty/pain on urination ___/___ Rashes (face/body/limb)
___/___Arm/hand numbness___/___ Difficulty with sexual function ___/___ Joint pain/swelling
___/___Arm/hand fatigue/weakness___/___Abnormal menstrual periods ___/___Pain with exertion
Dr. Stephanie Canada, D.C.
Hands on Health 1633 Fillmore St, #107, Denver, CO80206
HAVE YOU HAD:NOWEVER
___ Pain worse at night___ Recent bacterial infection___Cancer
___ Constant pain___ Loss of bowel/bladder control___IV drug use
___ Unexplained weight loss___ Urinary discharge___Blood transfusion
___ Recent surgery (30 days)
What is your primarycomplaint?______
Describe your pain______
Mark your pain level on the line ______
No pain Worst Pain
When did the problem start and how______
What makes you better______What makes you worse______
List any treatment for this to date______
What is your secondary complaint? ______
Describe your pain______
Mark your pain level on the line______
No painWorst Pain
When did the problem start and how______
What makes you better______What makes you worse______
List any treatment for this to date______
Primary Care Physician______
Notice to New Patients:Full payment for the chiropractic services rendered is due at the end of each visit. If you have insurance that covers chiropractic care, then your copay is due at each visit. If for any reason you cannot meet this financial requirement, the arrangements must be made in advance before seeing the doctor. We value and protect your privacy and our HIPPA plan is available on request.
______
SignatureDate
Dr. Stephanie Canada, D.C.
Hands on Health 1633 Fillmore St, #107, Denver, CO80206
303-778-9321