Confidential Chiropractic Case History
Patient Information
File #_______
Name
Address
City:
Sex: Male □ Female □
Marital Status: M S W D
Social Security Number:
Employer:
Spouse:
Occupation:
Children's names and ages:
How were you referred to our office?
State:
Zip:
Age:_____ Date of Birth:
Occupation:
Work Phone:
Employer:
-
Contact Information
Cell Phone_________________________________ Home Phone_______________________________
Email_______________________________________________________________________________
Preferred Appointment reminder contact method. Phone□ Email□ Both □
Emergency Contact:
Number:
Relationship:
Insurance
Do you have health insurance Yes□ No□
Name Primary Company:_____________________________________________________________
Name Secondary Company:___________________________________________________________
IF yes, Please present your card(s) to the Front Desk For processing.
Coordination of Care
When doctors work together it benefits you. May we have your permission to updated you medical doctor
regarding your care in this office? Yes □ No□
Clinic:
Doctor's Name:
AUTHORIZATION AND RELEASE: I authorize payment of insurance benefits directly to the chiropractor or
chiropractic office. I authorize the doctor to release all information necessary to communicate with personal
physicians and other healthcare providers and payors and to secure the payment of benefits. I understand that I am
responsible for all costs of chiropractic care, regardless of insurance coverage. I also understand that if I suspend or
terminate my schedule of care as determined by my treating doctor, any fees for professional services will be
immediately due and payable.
The patient understands and agrees to allow this chiropractic office to use their Patient Health Information for the
purpose of treatment, payment, healthcare operations, and coordination of care. We want you to know how your
Patient Health Information is going to be used in this office and your rights concerning those records. If you would
like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health
Information we encourage you to read the HIPAA NOTICE that is available to you at the front desk before signing
this consent.
Guardian's Signature Authorizing Care:___________________________________________________
Patients Signature___________________________________________________ Date______________
Doctors Signature___________________________________________________ Date______________
Confidential Chiropractic Case History
Present Condition
Reason for Visit:______________________________________________________________________
When did your symptoms start? _________________________________________________________
Describe your symptoms and how they began:
_____________________________________________________________________________________
_____________________________________________________________________________________
How often do you experience your
Indicate where you have pain or other symptoms.
symptoms?
□ Constantly (76-100% of the day)
□ Frequently (51-75% of the day)
□ Occasionally (26-50% of the day)
□ Intermittently (0-25% of the day)
What describes the nature of your
symptoms?
□ Sharp/stabbing
□ Numbness
□ Dull Ache
□ Burning
□ Stiffness
□ Tingling
How are your symptoms changing?
□ Getting Better
□ Not Changing
□ Getting Worse
How Bad are your Symptoms?
(1=no pain 10=worst pain possible)
Right now: 1 2 3 4 5 6 7 8 9 10
Average: 1 2 3 4 5 6 7 8 9 10
At Worst: 1 2 3 4 5 6 7 8 9 10
How do your symptoms affect your
What do you hope to get from treatment?
ability to perform daily activities? (0-10)
□ Reduce Symptoms
□ Become Pain Free
0
No Complaints
□ Resume/increase Activity
1
Mild-Forgotten
with
activity
□ Explanation of condition/treatment
2
□ Learn to take care for my condition
3
Moderate- interferes with
□ How to prevent this from occurring again
4
activity
□ Prevent future problems
5
6
Limiting- prevents full activity Have you had similar symptoms in the past?
□Yes □ No How long ago and how often______________
7
Have you seen another provider for these symptoms?
Intense- Preoccupied with
8
□Yes □No
If Yes. Who?______________________
seeking relief
9
What
have
you
tried to resolve this problem.
10
Severe- no activity possible □ Over the counter drugs
□ Surgery
What Makes your Symptoms better?
□ Prescription strength drugs □ Acupuncture
□ Physical Therapy
□ Nutritional Supplements
What Makes your symptoms worse?
□ Chiropractic
□ Other
□ Message Therapy
Patients Signature___________________________________________________ Date______________
Doctors Signature___________________________________________________ Date______________
Confidential Chiropractic Case History
Medical History
Mark symptoms you have now or have had in the past.
Past Present
Spine /Joints
Past Present
Past Present
Cardiovascular
□
□ High Blood Pressure
□
□ Low Blood Pressure
□
□ Chest Pain
□
□ Heart Attack
□
□ Stroke
□
□ Heart Disease
□
□ Pacemaker
□
□ Bruise Easily
□
□ Cold Hands/Feet
Gastrointestinal/Genitourinary
□
□ Kidney Stones
□
□ Kidney Disorder
□
□ Bladder Infection
□
□ Painful/Difficult Urination
□
□ Loss of Bladder Control
□
□ Prostate Problems
□
□ Unusual Weight Gain/loss
□
□ Loss of Appetite
□
□ Abdominal Pain
□
□ Ulcer
□
□ Hepatitis
□
□ Liver/Gall bladder Disorder
□
□ Indigestion
□
□ Diarrhea
□
□ Constipation
□
□ Heartburn/Reflux
Other Health Problems/Issues
1)
2)
3)
4)
General
□
□ Cancer
□
□ Diabetes
□
□ Excessive Thirst
□
□ Frequent Urination
□
□ Dermatitis/Eczema/ Rash
□
□ Unexplained Fever
Neurological
□
□ Dizzness
□
□ Loss Of Balance
□
□ Visual Disturbances
□
□ Seizures/Epilepsy
□
□ Ringing in the Ears
□
□ Weakness in Extremities
□
□ Fainting
□
□ Loss of Smell
□
□ Loss of Taste
□
□ Light Bothers Eyes
Respiratory
□
□ Shortness of Breath
□
□ Difficulty Breathing
□
□ Asthma
□
□ Allergies
□
□ Chronic Sinusitis
□
□ Frequent Colds
Females Only
□
□ Pregnancy
□
□ Birth Control Pills
□
□ Hormonal Replacement
□
□ Painful Menses
□
□ Other Menstrual problems
□
□ Infertility
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
Head aches
Neck pain
Stiff Neck
Upper Back Pain
Mid Back Pain
Low Back Pain
Shoulder Pain
Elbow/Upper Arm Pain
Wrist/ Lower Arm Pain
Hand Pain
Hip/Upper Leg Pain
Knee /Lower Leg Pain
Ankle/Foot Pain
Jaw Pain
□
□
□
□
□
□
□
□
Broken Bones
Joint Swelling/stiffness
Arthritis
Rheumatoid Arthritis
□
□ Numbness in Hands/Arms
□
□ Numbness in Legs/ Feet
□
□ Tingling in Hands/Arms
□
□ Tingling in Legs/Feet
Cognitive
□
□ Fatigue
□
□ Memory Loss
□
□ Depression
□
□ Anxiety
□
□ Irritability
□
□ Sleeping Problems
Family
History
Please indicate if any blood relative has had any of the following conditions, please check and indicate
which relative or child. Occasionally a patient's health problems and treatment are affected by
hereditary. Please help us to better understand factors that might affect your treatment.
□ Low Back Pain
□ Mid-Back Pain
□ Neck Pain
□ Stiff Neck or Back
□ Headaches
□ Migraines
□ Shoulder Pain
□Arm/ Hand Pain
□ Carpal Tunnel Syndrome
□ Hip Pain
□ Leg Pain/ Numbness
□ Sciatica
□ Foot / Ankle Pain
□ Anxiety
□Fibromyalgia
□ Muscle Cramps
□ Digestive Problems
□ Cancer
□ Arthritis
□ Constipation
□ Parkinson's
□ Scoliosis
□ Ear/Nose/Eye Problems
□ Alzheimer's
□ Thyroid Problems
□ Asthma
□ Allergies
□ Diabetes
□ Low/High Blood pressure
□ Cardiovascular Problems
□ Congenital Disorder
□ Other Medical Condition
Patients Signature___________________________________________________ Date______________
Doctors Signature___________________________________________________ Date______________
Confidential Chiropractic Case History
Exercise
Work Activity
Habits
□ none
□light
□ rarely
□moderate
□ regularly □ intense
□ daily
Are you Pregnant? Yes□ No□
Injuries/Surgeries you have had:
Falls:
□ Sitting
□ Standing
□ Light Labor
□ Heavy Labor
If Yes Due Date________
Description
□ Smoking
Packs/Day_____________
□ Alcohol
Drinks/Week___________
□ Coffee/Caffeine Drinks
Cups/Day______________
□ High Stress Level
Reason________________
If no, Date of last menstrual period_________________
Dates
Head Injuries:
Broken Bones:
Dislocations:
Surgeries:
Car Accidents:
Pregnancies: Number:____________
Medications
Type of birth(s): Vaginal□ ______ Caesarian □_______
Allergies
Vitamins/Herbs/Minerals
Medication/supplements taken for: □Pain □Muscle Relaxers □Blood Pressure/Heart □Allergy
□Birth Control □Anxiety □Depression □Insulin
□Seizure
Informed Consent for Examination and Treatment
Patients Name___________________________________________________________________________
Clinic Name: Living Motion Chiropractic
Doctor: Dr. Pauline Meyer DC
Address: 6536 Laketowne Place Suite B Albertville, MN 55301 Phone: 763-515-6656 Fax: 763-515-6658
I will use my hands or a mechanical Instrument upon your body in such a way as to move your joints. This
procedure is referred to as a "Spinal Manipulation" or " Spinal Adjustment". As the joint in your spine are moved, you
may experience a "pop" or "crack" as part of the process.
There are certain complications that can occur as a result of a spinal manipulation. These complications include,
but are not limited to: muscle strain, cervical myelopathy, disc and vertebral, fractures, strains and dislocations,
costovertebral strain and separation. Rare complication include, but are not limited to stroke. The most common
complication or complaint following spinal manipulation is an ache or stiffness at the site of adjustment.
I am aware of these complications, and in order to minimize their occurrence I will take precautions. These
precaution include but are not limited to my taking a detailed clinical history of you and examining you for any defect
which would cause a complication. This examination may include the use of x-rays. The use of x-ray equipment may
pose a risk if you are pregnant. If you are pregnant, you should tell me when I take your clinical history.
Patients Signature_____________________________________________________________ Date_____________
Signature of Guardian (if a minor)__________________________________________________________________
Patients Signature___________________________________________________ Date______________
Doctors Signature___________________________________________________ Date______________