<p>CASE HISTORY</p><p>TODAY’S DATE______PATIENT NAME______BIRTHDATE______AGE______SOCIAL SECURITY NUMBER #____-___-____ HEIGHT____’____” WEIGHT_____ SEX____ MARITIAL STATUS______NUMBER OF CHILDREN_____ ADDRESS______CITY______STATE___ ZIP______HOME PHONE ( ) _____-______CELL PHONE ( ) _____-______EMPLOYED BY______OCCUPATION ______WORK ADDRESS______CITY______STATE___ZIP______SPOUSE______SPOUSE SOCIAL SECURITY #_____-____-______INSURANCE CO______POLICY #______INSURANCE ADDRESS______CITY______STATE__ZIP______MEDICAL DOCTOR______CITY______STATE___ ZIP______ANY PAST CHIROPRACTIC CARE______DOCTOR’S NAME ______REFERRED BY ______PRESENT COMPLAINT______IS THE CONDITION DUE TO AN INJURY FROM WORK, AUTO OR OTHER? ______DAYS LOST FROM WORK? ______DATE SYMPTOMS APPEARED OR ACCIDENT HAPPENED? ______HOW DID YOU INJURE YOURSELF? ______WHERE DOES IT HURT? ______DOES THE PAIN RADIATE? ______WHERE? ______HAS THE PAIN BEEN CONSTANT OR INTERMITTENT? ______DESCRIBE THE PAIN______WHAT RELIEVES THE PAIN? ______WHAT MAKES THE PAIN WORSE? ______DOES IT AFFECT YOUR DAILY ACTIVITIES? ______HOW SO? ______ARE ANY OF THE ABOVE-MENTIONED COMPLAINTS RECURRING CONDITIONS? _____ DESCRIBE______DO YOU HAVE ANY OTHER COMPLAINTS? ______HAVE YOU TRIED ANY HOME REMEDIES? ______DO YOU TAKE ANY MEDICATIONS? ______WHICH? ______HAVE YOU HAD X-RAYSOF THE AREA? ____ WHERE? ______DO YOU SLEEP ON YOUR STOMACH, SIDE, OR BACK? ______HOW MANY PILLOWS DO YOU USE UNDER YOUR HEAD? ______DO YOU SLEEP ON A REGULAR BED OR WATER BED? ______COULD YOU BE PREGNANT? _____ LAST MENSTUAL CYCLE ______PREVIOUS HISTORY</p><p>IF ANY OF THE FOLLOWING APPLIES TO YOUR PAST HISTORY, PLEAST LIST</p><p>INJURIES: ______ACCIDENTS: ______FRACTURES: ______SURGERIES: ______MEDICATIONS: ______HOSPITALIZATIONS: ______HAVE YOU EVER BEEN DIAGNOSED WITH A DISEASE? ______DESCRIBE: ______HAVE YOU RECENTLY EXPERIENCED A WEIGHT CHANGE? ______DESCRIBE YOUR EXERCISE HABITS: ______</p><p>TO THE BEST OF MY KNOWLEDGE, ALL STATEMENTS MADE IN THE ABOVE CASE HISTORY ARE TRUE. (please initial) ______</p><p>PLEASE PLACE A CHECK BY ANY OF THE FOLLOWING OTHER SYMPTOMS THAT APPLY:</p><p>HEADACHES LOW BACK WEAKNESS NERVOUSNESS DIZZINESS HIP PAIN DEPRESSION NECK PROBLEMS LEG CRAMPS OR PAIN IRRITABLE SHOULDER PAIN NUMBNESS/TINGLING OF LEG CRYING SPELLS ARM/ELBOW PAIN ANKLE OR FOOT PAIN LOSS OF MEMORY NUMBNESS/TINGLING OF ARM LOSS OF CONCENTRATION KNEE TROUBLE HAND PAIN OR LOSS OF GRIP NUMBNESS/TINGLING OF FOOT DIFFICULTY SLEEPING NUMBNESS/TINGLING OF HAND ABDOMINAL PAIN EYE PROBLEMS PAIN BETWEEN SHOULDERS DIGESTIVE PROBLEMS ALLERGIES MID BACK PAIN OR TENSION KIDNEY PROBLEMS SINUS TROUBLE CHEST PAIN TAILBONE PAIN LOW ENERGY DIFFICULTY BREATHING CONSTIPATION FATIGUE ASTHMA DIARRHEA HIGH BLOOD PRESSURE LOW BACK PAIN REPRODUCTIVE PROBLEMS DIABETES LOW BACK STIFFNESS OVERWEIGHT SMOKER</p><p>I certify that the above information is true and correct. I hereby authorize the release of any information required. I also authorize my benefits payment to be paid directly to this clinic. I am financially responsible for non-covered services. In any event that this account remains unpaid, I agree to pay interest, all collection fees, court costs, and reasonable attorney fees. TODAY’S DATE ______PATIENT SIGNATURE ______</p>