Noonan Chiropractic



CASE HISTORY

Name_______________________________________________________ Date______________

Address_____________________________________City________________State______Zip________

Are you pregnant? Y N Are you here for: Complementary Consultation? Y N

Age_____ Birth Date__________Male____Female____ Status M S W D # of Children_________

Your Occupation________________________ Person Responsible for this Account____________________

Referred by____________________________

Employer’s Name and Address_______________________________________________________________

Home Telephone #__________________ Cell #:_________________Day Time Phone #_________________ Which is the Best # to Reach You __________________ Best Time of Day to Reach You ________________

Spouse’s Name______________________________Occupation _________________________

YOUR MAJOR COMPLAINT ____________________________________________________________

________________________________________________________________________________________

How Long Have You Had this Condition? ______________________________What Activities Aggravate Your Condition? __________________________________________________________________________

If an accident or traumatic event, please describe the events and result of the episode: __________________

______________________________________________________________________________________

How long has it been since you really felt good? _____________ Other Problems? Y N ( List Below)

What Would You Like The Doctor to Do For You _______________________________________________

_____________________________________________________________________________________

Help us know how to help you! Please check the following boxes if they pertain to you.

[ ] Plan To Use Insurance to Cover Fees [ ] HMO / PPO [ ] Medicare [ ] Retained An Attorney

[ ] Treated At Noonan Chiropractic Before [ ]Interested In Specific Chiropractic Technique (list)

[ ] Interested In A Particular Doctor [ ] Desire Acupuncture, Nutritional Advice, Lab Testing or Natural Medicine (Wellness Care) [ ] A Family Member Needs Care or I Desire Information About the Family Care Plan

1. About Your Pain or Problem: [ ] Had this or Similar in the past [ ] Is Getting Progressively Worse

[ ] Is Constant [ ] Comes and goes [ ] Interferes With: Work/ Sleep/ Daily routine [ ]Other

[ ]A chronic condition [ ] Just here for Checkup About Work: [ ] Missed Work [ ] Still off of Work

2. About Your Injury: [ ]Sports Injury [ ]A trauma [ ]Hurt on The Job [ ]Personal Injury /Auto Accident

[ ] Received Treatment 3. Do You: [ ] Wear: Heel lifts /Sole lifts /Inner soles /Arch supports [ ] Smoke

4. About Your Health: List below the specifics [ ]Any Surgical Operations [ ]Taking Prescription Medication

[ ] Non-prescription Drugs [ ] Taking Supplements or Vitamins [ ] Have Any Prior Accidents or Injuries

[ ] Have Any Recent X-rays/ MRI/ Urinalysis/ Blood tests/ Other Medical Tests [ ] Prior Chiropractic Care

|LIST | | |

|1 |Drugs/Medications | |

|2 |Vitamins/Supplements | |

|3 |Medical Tests | |

|4 |Surgeries | |

|5 |Other Complaints | |

|6 |Prior Accidents/ Injuries | |

PLEASE NOTE THIS FORM CONTINUES ON THE BACK SIDE.

Patient’s Signature _________________________________________________________ Date _______________

Please put a Υ next to all present symptoms.

HEAD: SHOULDERS: HIP, LEGS, AND FEET:

Headache Pain in shoulder joint R L Pain in buttocks

sinus (allergy) Pain across shoulders Pain in hip joint

entire head Bursitis R L Pain down leg R L

back of head Arthritis R L Pain down both legs

forehead Can’t raise arm Knee pain

temples above shoulder level Inside ____

migraine over head Outside ____

Head feels heavy Tension in shoulders Leg cramps

Loss of memory Pinched nerve in shoulder R L Cramps in feet

Light-Headedness Muscle spasms in shoulders Sensation of pins/needles in legs

Fainting Numbness of leg

Light bothers eyes MID BACK: Numbness of toes

Burred vision Mid-back pain Feet feel cold

Double vision Location_________________ Swollen ankles

Loss of vision Pain between shoulder blades Swollen feet

Loss of taste Sharp stabbing

Loss of balance Dull ache WOMEN ONLY:

Dizziness Pain from front to back Menstrual pain

Loss of hearing Muscle spasms Where _____________

Pain in ears Pain in kidney area Cramping

Ringing in ears Irregularity

Buzzing in ears CHEST: Cycle ______days

Chest pain Birth control

NECK: Shortness of breath Type ______________

Pain in neck Pain around ribs Hysterectomy

Neck pain with movement: Breast pain Genital cancer

Check all that apply Dimpled or orange peel breast Discharge

Forward Irregular heartbeat Menopause

Backward Tumors

Turn to left ABDOMEN: Abortions

Turn to right Nervous stomach Are you or do you think you

Bend to left Foods can’t eat_______________ are pregnant? Y N

Bend to right Nausea

Pinched nerve in neck Gas MEN ONLY:

Neck feels out of place Constipation Urinary frequency

Muscle spasms in neck Diarrhea Difficulty in starting

Grinding sounds in neck Hemorrhoids Night urination

Popping sounds in neck Prostrate pain/swelling

Arthritis in neck LOW BACK:

Low back pain: GENERAL:

ARMS AND HANDS: Upper lumbar (kidney area) Nervousness

Pain in upper arm Lower lumber (belt line) Irritable

Pain in elbow Sacroiliac (tailbone) Depressed

Movement aggravated Low back pain is worse when: Fatigue

Tennis elbow Working Generally feel run-down

Pain in forearm Lifting Normal sleep ____hrs/night

Pain in hands Stooping Loss of sleep ____hrs/night

Pain in fingers Standing Loss of weight ____lbs

Sensation of pins/needles in arms Sitting Weight gain ____lbs

Sensation of pins/ needles in fingers Bending Coffee ____cups/day

Numbness in arms R L Coughing Tea ____cups/day

Fingers go to sleep Lying down (sleeping) Cigarettes ____pack/day

Hands cold Walking Other __________________

Swollen joints in fingers Pain relieved when ______________ Diabetes

Sore joints in fingers Disk problems Hypoglycemia

Arthritis in fingers Low back feels out of place OTHER REMARKS: _______

Loss of grip strength Muscle spasms

Arthritis _________________________

_________________________

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