Case History Update

Paient First Name:        M.I.:        Patient Last Name:

Address: City: State: Zip:

Home Phone:   Work Phone:

Cell Phone:    Maritial Status:

Height: feet, inches     Weight: lbs.    Sex: Male Female

Date of Birth:    month 01 02 03 04 05 06 07 08 09 10 11 12   day   year        Email:

Date of accident:    month 01 02 03 04 05 06 07 08 09 10 11 12   day   year

Primary Insurance Company: Address:

Describe complaints:

Date symptoms began:

What caused symptoms?

Pain is now: mild   moderate   severe   dull    sharp    deep
                    improving    same    worse   

What helps the symtpoms?

What aggravates the symtpoms?

Describe any falls, accidents, surgeries since last visit:

Date of last physical: Date of last adjustment:

What were you previously treated in this office for?

Any work related or motor vehicle accidents in the last 2 years?   Yes    No

SYMPTOMS (check each symptom you have)

Stiffness / pain in neck      

Tingling or numbness in arms or fingers Right    Left

Pain in arms / hands Right    Left   

Headaches    Dizziness    Blurred Vision

Upper or mid back: Stiffness / pain       Tingling / numbness

Lower back: Stiffness / pain       Tingling / numbness

Leg pains Right Left       Elbow pain Right Left      

Shoulder pain Right Left

Wrist pain Right Left      Hip pain Right Left      

Knee pain Right Left

Ankle pain Right Left

Any other symptoms not listed:

List any previous diagnostic test: (X-rays, MRI, CT's, etc):