FALL CHIROPRACTIC

CONFIDENTIAL PATIENT CASE HISTORY1of 2

Today’s Date:______

Name: ______Phone: ______

Address: ______Work Phone: ______

City, State, Zip: ______Cell Phone:______

SS#: ______E-mail: ______

Birth Date: ______Age: ___ Sex: Male Female Marital Status: M S D W Separated

Employer: ______Occupation: ______

Emergency contact name: ______Phone number: ______

Spouse/Parent name:______Spouse/parent employer: ______

Primary Insured Name: ______SS#: ______

Insured Birthdate: ______Employer: ______

Primary Insurance Policy No.: ______Group #: ______

Secondary Insured Name: ______SS#: ______

Insured Birthdate: ______Employer: ______

Secondary Insurance Policy No.: ______Group #: ______

1. Most patients are referred to our office by a friend or family member. What made you decide to visit our office?

Friend/family member:______

Phone Call Yellow Pages Sign Newspaper Lecture Health Fair Radio Show

2. Research shows that your spine should be checked regularly. Have you ever been to a chiropractor? Yes No

Chiropractors names: ______

3. When was your last complete spinal examination including x-rays? ______Never

4. Poor posture leads to poor health and often indicates a spinal problem. How would you rate your posture?

Excellent Good Okay Not Good Terrible

5. Stress and Physical trauma causes and accelerates spinal damage.

Have you ever been in a car accident (even minor)?YesNoIf yes, when______

Have you everhad a fall or sports injury? YesNoIf yes, when______

Do you, or have you ever, worked at a desk or computer? YesNoIf yes, when______

Do you, or have you ever, had to do repeated lifting? YesNoIf yes, when______

How would you rate the amount of stress in your life? (1= low stress, 10=high stress) 1 2 3 4 5 6 7 8 9 10

7. Briefly describe symptoms you are presently suffering from: ______

______

8. Date symptoms appeared: ______Work days missed from injury:______to:______

9. Other doctors seen for this/these conditions: ______

10. Are your symptoms due to an accident? YesNoIf yes, when?______

Describe accident and when you first noticed the symptoms: ______

______

11. List any surgeries you have had and when: ______

12. Serious illness: ______

13. Do you have a pacemaker? YesNo

14. Family physician:______Name of referring doctor:______

FALL CHIROPRACTIC

CONFIDENTIAL PATIENT CASE HISTORY 2 of 2

CHECK ALL SYMPTOMS YOU HAVE HAD IN THE PAST 12 MONTHS:

Neck subluxations

 Tension in shoulders/Neck pain

 Headaches/Migraines

 TMJ

 Carpal Tunnel Syndrome

 Loss of balance

 Ringing in ears

 Thyroid/Throat problems

 Numbing/Tingling in arms/hands

 Allergies/Asthma

 Dizziness

 Arthritis/Joint pain

 Fibromyalgia

 Poor Vision/Eye problems

 Difficulty sleeping

 Tinnitus/Hearing problems

 Depression/ADD/ADHD

 Frequent colds

Midback subluxations

 Breathing problems

 Heart burn

 Diabetes/Blood sugar

 Digestive problems

 Eczema/Psoriasis/Dry skin

 Acid Reflux/Stomach

 Fatigue/Low Energy

 Stress-related problems

 Autoimmune/Rheumatism

Lowback subluxations

 Gas/Bloating

 Irritable Bowel Syndrome

 Constipation/Diarea

 Infertility/Inability to get pregnant

 Menstrual problems/PMS

 Numbing/Tingling in legs/feet

 Prostate problems

 Frequent urination

 Sciatica/Leg pain

 Knee/Ankle/Hip problems

 Sexual Dysfunction

 Muscle pain in hips/buttocks

PRESCRIPTION DRUGS:

______

What for?

______

Side effects:

______

1.Auto and work-related injuries can cause serious spinal problems.

Is this visit related to an accident or injury? Yes No If yes, when was it? ______

2. Spinal health is especially important during pregnancy. Is there any chance you are pregnant?

Yes NoIf yes, what trimester? ______

3. Children experience spinal stress and trauma. If not found early they lead to problems later in life.

Have your kids ever had a spinal checkup by a chiropractor?

Yes No If yes, when? ______

4. How would you rate your health in the following categories (1 = bad, 10 = perfect)?

ENERGY LEVELS (without caffeine or other stimulants)1 2 3 4 5 6 7 8 9 10

MENTAL CLARITY (without caffeine or other stimulants)1 2 3 4 5 6 7 8 9 10

SLEEP QUALITY (how refreshed you feel in the morning)1 2 3 4 5 6 7 8 9 10

FLEXIBILITY (ease of movement, bending, turning, etc.) 1 2 3 4 5 6 7 8 9 10

DIGESTIVE HEALTH (normal is 2-4 bowel movments/day) 1 2 3 4 5 6 7 8 9 10

OVERALL HEALTH1 2 3 4 5 6 7 8 9 10

5. If you keep doing the same things you are doing and fail to make proper changes, what do you see

happening to your health in the next 5 years? Spontaneous improvement Same Gradually worse

6. What is your goal for your care in our office:

Pain relief onlyFull correction of problemOptimal health and wellness

Release of Information: By signing below, I agree to allow Fall Chiropractic to post pictures, articles, and/or testimonials about me on bulletin boards. Signed: ______Date: ______

Informed Consent: Spinal manipulation has been proven a very safe procedure. However, there can be slight risk of Soreness, Fracture, TIA/Stroke, and/or Ruptured/Herniated Disc. Dr. Fall does a careful manual full spinal approach adjustment. I have read the above, am fully aware of the risks associated with spinal manipulation and agree to undergo chiropractic care. Signed: ______Date: ______