PATIENT CASE HISTORY FORM
NAME ___________________________________	DATE _______________________
NECK       Pain is: Severity is: Quality is: Pain is on: ___ Constant ___ Mild ___ Aching ___ Left Side ___ Off & On ___ Moderate ___ Burning ___ Right Side ___ Came Suddenly ___ Severe ___ Numbness ___ Both sides/Center ___ Came Gradually   Other _________ BACK       Pain is: Severity is: Quality is: Pain is on: ___ Constant ___ Mild ___ Aching ___ Left Side ___ Off & On ___ Moderate ___ Burning ___ Right Side ___ Came Suddenly ___ Severe ___ Numbness ___ Both sides/Center ___ Came Gradually   Other _________
Pain/Numbness in Legs/Arms: ________________________________________________________
Other Complaints: ___________________________________________________________________
Explain When and How it happened: ______________________________________________________
_________________________________________________________________________________
Pain Level: On a scale of 0-10, with 0 being you are pain free and 10 being your pain is at its worst, rate yourself.
Neck ____ LowBack ____ MidBack ____ Headache ____ Other ____ (0 1 2 3 4 5 6 7 8 9 10)
_________________________________________________________________________________
What makes condition Worse? _____________________________________
What makes condition Better? __________________________________________
Pain/Discomfort is Worse in: ___am ___pm
Is your pain getting:     BETTER     WORSE     STAYING THE SAME
Have you had this problem before: ___No, If Yes, when? ______________________________________________
Describe other Dr.'s treatment: ___________________________________________________________________
Drugs you now take:   ___Pain Killers   ___Muscle Relaxers   ___Anti-inflammatory          ___Birth Control Others_________________________________
Any past car accidents, falls/trauma ever: __________________________________________________
Past surgeries: __________________________________________________________________
Related family history: ______________________________________________________________
Have you ever had a broken leg? __ Yes __ No Have you ever had knee surgery? __ Yes __ No Do you wear a heel lift? __ Yes __ No Previous Chiropractic Care? __ Yes __ No Loss of bowel/bladder control? __ Yes __ No Do you smoke? __ Yes __ No Pregnant? Yes/No Sign _____________________ Beginning date of last menstrual cycle: _____/_____/_____. Shade areas of Pain/Discomfort __Headache __Constipation __Diarrhea __HIV+ __Sinus/Allergy __Hemorrhoids __Itching __Dizziness/Nausia __Asthma __Poor Circulation __Fatigue __Deafness __Bladder Problems __Loss Of Sleep __Ear Noises __Kidney Problems __Ulcers/Indigestion __Eye Pain __Hot Flashes __Nervous/Depressed __High Blood Pressure __Irregular Cycle __Arthritis __Diabetes __Cancer