Kelly Weaver, BA, RYT-200, HC, Therapeutic Yoga Specialist

Dr. Christopher Weaver, DC Kelly Weaver, BA, RYT-200, HC, Therapeutic Yoga Specialist

CASE HISTORY Name ______Age ______Date ______Address ______City ______State_____ Zip______Phone (Home) ______Date of Birth ______Sex: M F Marital Status: S M D W Social Security # ______Driver’s License #______Occupation Employer ______Phone (Work)______Spouse’s Name ______Spouse’s Occupation ______Spouse’s Employer ______Spouse’s Phone (Work)______Spouse’s Social Security # ______Present condition due to an injury? __ Yes __ No __ On the Job __ Auto Accident __ Other ______Has the accident been reported? __ Yes __ No __ To Employer __ Auto Carrier __ Other ______HEALTH REPORT: Reason for seeking care: ______List any other doctors seen for this: ______List any diagnosis and type of treatment: ______Have you had similar accidents or injuries before? __ Yes __ No If yes, explain: ______List the names of any relatives that have or have had a similar problem: ______Have you or any relative received chiropractic treatment previously? __ Yes __ No If yes, explain: ______Have you been treated for any health condition by a physician in the last year? __ Yes __ No If yes, explain: ______Are you currently taking medication? __ Yes __ No list medications: ______Have you taken medication in the past? __ Yes __ No list medications ______List conditions you are taking medications for: ______List the approximate dates of any surgery or treated conditions:______Family History: Health conditions, age of death and cause of death. Father: ______Mother: ______Brother/s & Sister/s: ______Do you smoke Y/N ____ Alcohol Y/N __Daily __Weekly __Social Occasions Caffeinated drinks per day ____ Do you take Vitamins/Supplements Y/N If yes, type and how often ______Please circle degree of pain, 0 none, 10 severe pain. 0 1 2 3 4 5 6 7 8 9 10 Using the symbols below, mark on the pictures where you feel pain. Numbness = = = Dull Ache OOO Burning XXX Sharp/Stabbing / / / Pins, Needles + + + Other ______^ ^ ^ What activities aggravate your condition/pain?______What activities lessen your condition/pain?______Is this condition worse during certain times of the day? Y/N Is this condition interfering with Work?______Sleep?______Routine?______Other?______Is this condition progressively getting worse?______

Please mark each item below for each sign or symptom you presently have or previously had:

GENERAL SYMPTOMS EAR/NOSE/THROAT RESPIRATORY __ Convulsions __ Earache __ Asthma __ Dizziness __ Ear Noises __ Chronic Cough __ Fainting __ Enlarged Thyroid __ Difficulty Breathing __ Headache __ Frequent Colds __ Spitting Blood __ Nervousness __ Hay Fever __ Spitting Phlegm __ Numbness __ Nasal Blockage GENITO-URINARY __ Wheezing __ Nose Bleeds __ Blood in Urine MUSCLES & JOINTS __ Pain Behind Eyes __ Frequent Urination __ Low Back Problems __ Poor Vision __ Kidney Infection __ Pain between Shoulders __ Sinusitis __ Painful Urination __ Neck Problems __ Sore Throats __ Prostate Problems __ Arm Problems __ Tonsillitis __ Loss of Bladder Control __ Leg Problems GASTRO-INTESTINAL SKIN OR ALLERGIES __ Swollen Joints __ Belching/Gas __ Boils __ Painful Joints __ Colon Problems __ Bruising Easily __ Stiff Joints __ Constipation __ Dryness __ Sore Muscles __ Diarrhea __ Eczema/Rash/Dermatitis __ Weak Muscles __ Excessive Hunger __ Hives __ Walking Problems __ Excessive Thirst __ Itching __ Sprains/Strains __ Gall Bladder Trouble __ Sensitive Skin __ Broken Bones __ Hemorrhoids __ Allergy ______CARDIO-VASCULAR __ Liver/Gallbladder FOR WOMEN ONLY __ High Blood Pressure __ Nausea __ Birth Control ______Heart Attack __ Abdominal Pain __ Hormone Replacement __ Pain over Heart __ Ulcer __ Cramps/Backaches __ Poor Circulation __ Poor Appetite __ Excessive Flow __ Heart Trouble __ Poor Digestio __ Hot Flashes __ Rapid Heart __ Vomiting __ Irregular Cycle __ Slow Heart __ Vomiting Blood __ Miscarriage __ Strokes __ Black Stool __ Painful Periods __ Swelling Ankles __ Bloody Stool __ Vaginal Discharge __ Varicose Veins __ Weight Loss/Gain __ Breast Pain Pregnant at this Time Y/N

I hereby certify that the statements and answers given on this form are accurate to the best of knowledge and understand it is my responsibility to inform this office of any changes in my health. I agree to allow this office to examine me for further evaluation. Patient Signature______Date______