Chiropractic Case History
Name______________________________________________ Sex M F Date_________________________
Address___________________________________ City_______________________ State______ Zip_________
H. Phone______________________ C. Phone_______________________ W. Phone______________________
Age______ Date of Birth_______________ SS#_________________ Referred By _________________________
Occupation_________________________________________ Employer_________________________________
Have you ever received chiropractic care? Yes No If yes, when? _______________________________
1. Primary Reasons for Seeking Chiropractic Care:
Primary Reason: _____________________________________________________________________________
Secondary Reason: _ _________________________________________________________________________
2. Chief Complaint: _________________________________________________________________________
Location of Complaint: _______________________________________________________________________
Complaint began when and how? _______________________________________________________________
Please circle the quality of the pain: dull aching sharp shooting burning throbbing deep nagging other _______
Does the pain radiate or travel (shoot) to any areas of your body? Y N Where? _________________________
Do you have any numbness/tingling in your body? Y N Where? ____________________________________
On a scale from 1-10, rate the severity of your pain (1-little/no pain) 1 2 3 4 5 6 7 8 9 10 (10-worst pain ever)
How often is the complaint present and how long does it last? _________________________________________
Does anything make the complaint worse? ________________________________________________________
Does anything make the complaint better? ________________________________________________________
3. Please list any previous treatments, medications, surgery, interventions, or care you have sought for your
complaint: ________________________________________________________________________________
4. Past Health History
Previous illnesses you have had throughout your life: _______________________________________________
________________________________________________________________________________________
Previous injuries or traumas: __________________________________________________________________
________________________________________________________________________________________
Have you ever broken any bones? Y N Which? ________________________________________________
Please list any allergies (including medication): ____________________________________________________
_______________________________________________________________________________________
Port Orange Chiropractic●3729 S Nova Rd Port Orange, FL 32129●386-761-0520
Chiropractic Case History Continued
Patient Name: ______________________________________________ Date:____________________________
Please list any medications that you are currently taking:
Medication Reason for taking
________________________________________ _________________________________________
________________________________________ _________________________________________
________________________________________ _________________________________________
Please list any major surgeries:
Date Type of Surgery Complications? Successful?
___________________ ______________________ _________________________________________
___________________ ______________________ _________________________________________
___________________ ______________________ _________________________________________
Females only/Pregnancies & Outcome
Pregnancies/Delivery Date Outcome
____________________________________________ _________________________________________
____________________________________________ _________________________________________
Beginning date of your last menstrual period? ______________________________________________________
5. Family Health History
Associated health problems of relatives: ___________________________________________________________
__________________________________________________________________________________________
Deaths in immediate family?
Relation and cause of death Age at death
________________________________________________________________ _____________________
________________________________________________________________ _____________________
________________________________________________________________ _____________________
6. Social and Occupational History
Education Completed: □ High School □ GED □ Some College □ College Graduate □ Post Graduate Studies
Job Description: ____________________________________________________________________________
Work Schedule: ____________________________________________________________________________
Recreational Activities: _______________________________________________________________________
Lifestyle (hobbies, level of exercise, alcohol, tobacco, drug use, diet): ____________________________________
_________________________________________________________________________________________
I have completed and understand the above information and certify it to be true and correct to the best of my knowledge, and
hereby authorize Port Orange Chiropractic to provide me with chiropractic care, in accordance with this state’s statues.
Patient’s Signature: ______________________________________________ Date: ______________
Doctor’s Signature: ____________________________________________ Date: ______________
Port Orange Chiropractic●3729 S Nova Rd Port Orange, FL 32129●386-761-0520