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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