Ethan Frome - Forté360



QUICKCHARTS PATIENT CASE HISTORY

Name: _________________________________________________________________________

Address: _______________________________________________________________________

City: ___________________________ State: ____________ Zip: _________________________

Home Phone: ______-______-_______Work Phone: ______-______-_______ Cell Phone: ______-______-___________

Email Address: _____________________________ Occupation: _____________________________________________

Date of Birth: ________________________ Social Security #: _______-______-_______ Gender: Male - Female

List any Allergies:

ζ Animals ζ Aspirin ζ Bees ζ Chocolate ζ Dairy ζ Dust ζ Eggsζ Latex ζ Molds ζ Penicillin ζ Ragweed/Pollen

ζ Rubber ζ Seasonal Allergies ζ Shellfish ζ Soaps ζ Wheat ζ X-Ray Dye ζ Other: ____________________________

List any Surgeries:

ζ Back ζ Brain ζ Elbow ζ Foot ζ Hip ζ Knee ζ Neck ζ Neurological ζ Shoulder ζ Wrist ζ Other: ______________

List ALL Past Medical History conditions:

ζ Ankle Pain ζ Arm Pain ζ Arthritis ζ Asthma ζ Back Pain ζ Broken Bones ζ Cancer ζ Chest Pain ζ Depression

ζ Diabetes ζ Dizziness ζ Elbow Pain ζ Epilepsy ζ Eye/Vision Problems ζ Fainting ζ Fatigue ζ Foot Pain

ζ Genetic Spinal Condition ζ Hand Pain ζ Headaches ζ Hearing Problems ζ Hepatitis ζ High Blood Pressure

ζ Hip Pain ζ HIV ζ Jaw Pain ζ Joint Stiffness ζ Knee Pain ζ Leg Pain ζ Menstrual Problems ζ Mid-Back Pain

ζ Minor Heart Problem ζ Multiple Sclerosis ζ Neck Pain ζ Neurological Problems ζ Pacemaker ζ Parkinson’s

ζ Polio ζ Prostate Problems ζ Shoulder Pain ζ Significant Weight Change ζ Spinal Cord Injury ζ Sprain/Strain

ζ Stroke/Heart Attack ζ Other: ________________________________________________________________________

List Type of Medications you are taking:

ζ Anxiety ζ Muscle Relaxors ζ Pain Killers ζ Insulin ζ Birth control ζ Cardiovascular ζ Allergy ζ Seizure

ζ Other: _________________________________

List your Family History:

ζ Arthritis ζ Asthma ζ Back Pain ζ Cancer ζ Depression ζ Diabetes ζ Epilepsy ζ Genetic Spinal Condition

ζ High Blood Pressure ζ Heart Problems ζ Multiple Sclerosis ζ Neurological Problems ζ Parkinson’s ζ Polio

ζ Prostate Problems ζ Stroke/Heart Attack ζ Other: _______________________________________________________

Have you had any auto or other accidents? ζ No ζYes

Describe: ___________________________________________________________________________________

Date of last physical examination: _________________ Do you smoke? ζ No ζYes

Do you drink alcohol? ζ No ζYes - how many per day? _________________

Do you drink caffeine? ζ No ζYes - how many per day? _________________

Do you exercise? ζ No ζYes (what forms and how often): ___________________________________________________

What is your major complaint? _________________________________Date problem began? _____________________

How did this problem begin (falling, lifting, etc.)? _________________________________________________________

How is your condition changing? ζ GETTING BETTER ζ GETTING WORSE ζ NOT CHANGING

Have you had this condition in the past? YES - NO

How often do you experience your symptoms?

ζ Constantly (76-100% of the day) ζ Frequently (51-75% of the day)

ζ Occasionally (26-50% of the day) ζ Intermittently (0-25% of the day)

Describe the nature of your symptoms: ζ Sharp ζ Dull ζ Numb ζ Burning ζ Shooting ζ Tingling ζ Radiating Pain

ζ Tightness ζ Stabbing ζ Throbbing ζ Other: __________________________________________________________

Please rate your pain on a scale of 1 to 10 (0= no pain and 10= excruciating pain)

ζ 1 ζ 2 ζ 3 ζ 4 ζ 5 ζ 6 ζ 7 ζ 8 ζ 9 ζ 10

How do your symptoms affect your ability to perform daily activities such as working or driving?

(0= no effect and 10= no possible activities) ζ 1 ζ 2 ζ 3 ζ 4 ζ 5 ζ 6 ζ 7 ζ 8 ζ 9 ζ 10

What activities aggravate your condition (working, exercise, etc)? _____________________________________________

What makes your pain better (ice, heat, massage, etc)? ______________________________________________________

What is your SECOND complaint? _________________________________Date problem began? _____________________

How did this problem begin (falling, lifting, etc.)? _________________________________________________________

How is your condition changing? ζ GETTING BETTER ζ GETTING WORSE ζ NOT CHANGING

Have you had this condition in the past? YES - NO

How often do you experience your symptoms?

ζ Constantly (76-100% of the day) ζ Frequently (51-75% of the day)

ζ Occasionally (26-50% of the day) ζ Intermittently (0-25% of the day)

Describe the nature of your symptoms: ζ Sharp ζ Dull ζ Numb ζ Burning ζ Shooting ζ Tingling ζ Radiating Pain

ζ Tightness ζ Stabbing ζ Throbbing ζ Other: __________________________________________________________

Please rate your pain on a scale of 1 to 10 (0= no pain and 10= excruciating pain)

ζ 1 ζ 2 ζ 3 ζ 4 ζ 5 ζ 6 ζ 7 ζ 8 ζ 9 ζ 10

How do your symptoms affect your ability to perform daily activities such as working or driving?

(0= no effect and 10= no possible activities) ζ 1 ζ 2 ζ 3 ζ 4 ζ 5 ζ 6 ζ 7 ζ 8 ζ 9 ζ 10

What activities aggravate your condition (working, exercise, etc)? _____________________________________________

What makes your pain better (ice, heat, massage, etc)? ______________________________________________________

What is your major complaint? _________________________________Date problem began? _____________________

How did this problem begin (falling, lifting, etc.)? _________________________________________________________

How is your condition changing? ζ GETTING BETTER ζ GETTING WORSE ζ NOT CHANGING

Have you had this condition in the past? YES - NO

How often do you experience your symptoms?

ζ Constantly (76-100% of the day) ζ Frequently (51-75% of the day)

ζ Occasionally (26-50% of the day) ζ Intermittently (0-25% of the day)

Describe the nature of your symptoms: ζ Sharp ζ Dull ζ Numb ζ Burning ζ Shooting ζ Tingling ζ Radiating Pain

ζ Tightness ζ Stabbing ζ Throbbing ζ Other: __________________________________________________________

Please rate your pain on a scale of 1 to 10 (0= no pain and 10= excruciating pain)

ζ 1 ζ 2 ζ 3 ζ 4 ζ 5 ζ 6 ζ 7 ζ 8 ζ 9 ζ 10

How do your symptoms affect your ability to perform daily activities such as working or driving?

(0= no effect and 10= no possible activities) ζ 1 ζ 2 ζ 3 ζ 4 ζ 5 ζ 6 ζ 7 ζ 8 ζ 9 ζ 10

What activities aggravate your condition (working, exercise, etc)? _____________________________________________

What makes your pain better (ice, heat, massage, etc)? ______________________________________________________

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PLEASE MARK YOUR AREAS OF PAIN ON THE DIAGRAM BELOW

Main reason for consulting the office:

ζ Become pain free

ζ Explanation of my condition

ζ Learn how to care for my condition

ζ Reduce symptoms

ζ Resume normal activity level

Have you ever had chiropractic care? ( No ( yes

When? ____________Why? __________________

Where? ___________________________________

Were X-rays taken? ( No ( Yes

When was your last adjustment? _______________

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