CONFIDENTIAL PATIENT CASE HISTORY
ERINDALE CHIROPRACTIC HEALTH CENTRE
CONFIDENTIAL PATIENT CASE HISTORY
Name______________________________________________ Age___________ Date_________________________________
Address _________________________________________ City __________________________Postal Code_______________
Home Phone _____________ Work Phone ____________ Cellular ________________ Birth Date_____________________
Work Address __________________________________________________________ Referred By:_____________________
Occupation ______________________________________ Email Address __________________________________________
Health Card # ____________________________________
Is this a Worker’s Compensation Injury? SGI? Claim #________________________________________
Dear Patient:
Your health is our priority. This form will help us more adequately assess your need for care.
Health Information: Height: _____________________ Weight: _____________________
Have you had previous chiropractic care? Yes No By whom? ________________________________________
When? _______________________ For what condition? ____________________________________________________
Medical Doctor’s Name: ____________________________________ Last seen? ___________________________________
List surgical operations and years: _____________________________________________________________________________________________________
Drugs you now take or have taken in the past year: Pain Killers Muscle Relaxants Corticosteriods
Anti-Coagulants/Blood Thinners Vitamins/Supplements
Please list the names and dosages of the drugs/supplements that you are taking: _________________________________
_____________________________________________________________________________________________________
Have you ever been in an auto accident? Yes No When? ____________________________________________
Have you received any care for injuries sustained in your auto accident? Physio Therapy Chiropractic MD
Massage Therapy Other _______________________
Had you ever had x-rays taken of your spine? Yes No When ___________________________________________
Do you sleep well? Yes No What position do you sleep in? Back Stomach Side
Do you participate in a regular exercise program? Yes No Describe ___________________________________
Have you been diagnosed with any of the following: Diabetes High Blood Pressure Arthritis Cancer
Stroke Transcient Ischemic Attack High Cholesterol
Primary Complaints (reason for consulting the clinic): __________________
_________________________________________________________________
Secondary Complaint, if any (describe): ______________________________
________________________________________________________________
Please describe what activities you do on a daily basis (lifting, typing,
prolonged sitting/standing) :________________________________________
1. How long have you had your primary complaint? ___________________________________________________________
________________________________________________________________________________________________________
2. How did it start? ______________________________________________________________________________________
________________________________________________________________________________________________________
3. Is it getting worse, better, or staying the same? ____________________________________________________________
________________________________________________________________________________________________________
4. What makes it worse? _________________________________________________________________________________
________________________________________________________________________________________________________
5. What makes it better? _________________________________________________________________________________
________________________________________________________________________________________________________
6. What type of previous treatment have you had for this condition: Chiropractic Massage Therapy MD
Physio Therapy Other ______________________
7. Have you had a similar problem before? Yes No When? __________________________________________
Health Conditions: Please underline any conditions which are presently causing you a problem
RESPIRATORY NEUROLOGICAL GASTRINTESTINAL CARDIOVASCULAR MUSCLE ANDJOINT
Chronic cough Visual disturbances Nausea High Blood Pressure Stiff Neck
Chest pain Co-ordination difficulties Vomiting Hardening of arteries Back Ache
Difficulty breathing Dizziness Diarrhea Swelling of ankles Neck pain
Asthma Slurred speech Constipation Swollen joints
Headache Foot trouble
Facial numbness Spinal curvature
Difficulty swallowing Faulty posture
Arthritis
List any other medical concerns not listed: ______________________________________________________________
___________________________________________________________________________________________________
Family Health History Diabetes Cancer Other List:____________________________________
Father ( ) ( ) ( ) ______________________________________
Mother ( ) ( ) ( ) ______________________________________
Siblings ( ) ( ) ( ) _______________________________________
Children ( ) ( ) ( ) _______________________________________
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