Case History
PLEASE PRINT!
Name: _____________________________________________________________ Date: _____________
First Middle Last
Address: ____________________________________________ City: __________________ Zip: _______
Phone Home:______________________ Work: ______________________ Cell: __________________
Email: _______________________________________________
(used to confirm appointments and in office communications)
Sex: _____ Female _____Male Birth date: ________________________ Age: _____________
How were you referred to Safe Harbor Chiropractic? ____________________________________________
Occupation: _______________________________ Employer: __________________________________
Marital Status ____Single ____Married ____Separated ____Divorced ____Partner ____Widowed
Is your present condition due to an injury? ____Yes ____No ____On the job ____Auto ____Other
Has the accident been reported: ____Yes ____No ____To Employer ____ Auto Carrier
Have you received chiropractic treatment previously? _____Yes _____No
If yes, explain: _________________________________________________________________________
Were you pleased with your chiropractic care? ____Yes ____No
________________________________________________________________________________________
________________________________________________________________________________________
When did this problem begin? _______________________________________________________________
Have you had anything like this before? _______________________________________________________
Is it getting better, worse or no change? _______________________________________________________
List any doctors seen for this: ______________________________________________________________
List any diagnosis and treatment/outcomes: ___________________________________________________
______________________________________________________________________________________
List medications taking for this condition: _____________________________________________________
Does anything make it better? ____ Ice ____ Heat ____ Rest ____ Lying down ____Other__________
How long have you had this health concern? _________________________________________________
Is your condition _____Getting Worse _____Improving ______Intermittent _______Constant
Do you have: ____Achiness ____Numbness _____Tingling ________Sharp/Shooting
______Throbbing _____ Tightness ____Cramps _____Stiffness
_____Swelling _____Burning _____ ____ Pain radiates ___Other_____
Any of the following interfere with activities of daily living:
____ Sleep _____Sitting _____Walking ________Lying down _______Standing ____Any motion
____ Coughing _____ Having a bowel movement ______Weather _____ Bending
Any other symptoms associated with your concern: _____________________________________________

Case History
Use the following scales to answer the three questions below:
1 =no pain or discomfort 2 =slight discomfort 3 =pain that does not affect my activity
4 =pain that affects my daily activities 5 =pain that prevents performing my daily activities
6 =pain that limits my work schedule 7 = pain that prevents working at all
8 =pain that prevents working and all personal activity
9 =pain that keeps me bedridden 10 = pain that causes thoughts of suicide
1 . Rate the severity of your pain today (1, mild pain or discomfort, to 10, severe pain)
1 2 3 4 5 6 7 8 9 10
2.
Rate the severity of your pain at its worst (1, mild pain or discomfort, to 10, severe pain)
1 2 3 4 5 6 7 8 9 10
3.
Rate the severity of your pain at its least (1, mild pain or discomfort, to 10, severe pain)
1 2 3 4 5 6 7 8 9 10
Current medications, reason and length of time:
________________________________________________________________________________________
________________________________________________________________________________________
Current vitamins/supplements, reason and length of time, are they prescribed, are you getting results?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Check only those conditions which are applicable:
___AIDS/HIV
___Alcoholism
___Allergy Shots
___Anemia
___Anorexia
___Appendicitis
___Arthritis
___Cataracts
___Chemical Dependency
___Chicken Pox
___Depression
___Diabetes
___Emphysema
___Epilepsy
___Bleeding disorders ___Glaucoma
___Vaginal infections ___Breast lump
___Bronchitis
___Stroke
___Gout
___Metabolic Disorder
___Arm/back tingling ___Shoulder pain
___Lung problems ___Blood pressure issues
___Difficulty breathing ___Stuffy nose
___Poor appetite ___Excessive appetite
___Excessive thirst ___Frequent nausea
___Discolored urine ___Gas/bloating
___Black stools
___Tired after 2pm
___Bloody stools
___Wake up b/t 1&3 am
___Excessive urination
___Hepatitis
___Hernia
___Herniated Disc
___Osteoporosis
___Pacemaker
___Parkinson’s Ds
___Suicide Attempt
___Thyroid Problems
___Tonsillitis
___Herpes
___High Cholesterol
___Kidney Disease
___Liver Disease
___Pinched Nerve
___Pneumonia
___Polio
___Tuberculosis
___Tumors
___L yme’s disease
___Prostate Problems ___Ulcers
___Headaches
___Goiter
___Psychiatric Care ___Fractures
___Miscarriage ___Venereal Disease
___Multiple Sclerosis ___Cancer
___Neck Pain ___Low back pain
___Heart Problems
___Migraines
___Hand pain/tingling ___Leg pain/tingling ___Jaw pain
___Ankle swelling
___Allergies
___Nervousness
___Cold hands/feet
___Fainting
___Confusion
___Blurred vision
___Weight loss
___Dental problems
___Vomiting
___Heartburn
___Eczema
___Constipation
___Loss of sleep
___Painful urination ___Bladder trouble
___Colitis ___Irritable bowel
___Hemorrhoids ___Fatigue
___Difficulty hearing ___Ear pain

Case History
Have you had any surgeries? If yes, please describe: ______________________________________________
_________________________________________________________________________________________
Women only :
Date of last menstrual period: _____________________________________________________
Do you have the following occur with your periods: ___ Painful cramping ___Heavy ____Long lasting
___Migraines ___Clotting ___Fatigue ____Leg weakness _____Bowel habit changes
Any abnormal PAP or mammograms? ______ Yes _____No
If so, please explain: ____________________________________________________________________
Do you have hot flashes?
Do you have night sweats?
____Yes
____Yes
____No
____No
Do you have insomnia?
Do you have memory loss?
Do you have mood swings?
Do you have low sex drive?
____Yes
____Yes
____Yes
____Yes
____No
____No
____No
____No
Do you have fatigue? ____Yes
Do you have breast tenderness? ____Yes
Do you have Weight gain?
Do you have anxiety?
____Yes
____Yes
____No
____No
____No
____No
Men only:
Do you have decreased urinary flow? ____Yes _____No
Do you have abdominal weight gain? ____ Yes _____No
Do you have elevated cholesterol? ____Yes
Do you have erectile dysfunction? ____Yes
_____No
_____No
Do you have depression/anxiety? ____Yes
Do you have fatigue? ____ Yes
_____No
_____No
Do you have loss of muscle tone? ____Yes
Do you have irritability? ____Yes
Difficulty concentrating? ____Yes
_____No
_____No
_____No
Date of last prostate exam: ____________ Any abnormalities? If so, please explain: ____________________
_______________________________________________________________________________________
Family Health History:
___Diabetes
___Alcoholism
___Osteopenia
___Osteoarthritis
___Mental Illness ___Kidney Disease
___Depression
___Arthritis
___Eye Disorders
___Liver Disease
___Thyroid Problems
___Lung Disease
___High Cholesterol
___Liver Disease
___High Blood Pressure
___Cancer
___Autoimmune Disorders
___Digestive Disorders
___Osteoporosis
___Addictions
___Other ______________________________________________________________________________
Please elaborate on any of the above. Also, please list the family member with the health issue
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

Case History
Do you exercise? ____ Yes ___No
What level of exercise do you perform on a regular basis? ____None ___Light ___Moderate ___Heavy
What exercises are you doing, frequency and for how long? _________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Are you achieving the results you expect from your current exercise program? ___Yes ___No
Do you have a personal trainer? _________________________________________________
Do you smoke cigarettes, tobacco, recreational? ____ Yes ___No How much per day? _________________
How much wine, beer, and hard liquor do you consume on a daily or weekly basis? ________________________
How much coffee, soda, or caffeinated beverages to you consume on daily basis? _________________________
Do you feel rested and refreshed when you wake up? ____Yes ____No
How many hours do you sleep each night? ______________
Do you snore? ___Yes ___No
Do you sleep on your ____ Stomach ____ Sides ____ Back
Do you use a pillow between your knees when you sleep? ____ Yes ___ No
Do you use a pillow under your knees when you sleep on your back? ___Yes ___No
Do you sit on your cell phone or wallet in the car or at work? _____Yes ____No
Do you eat breakfast? ___Yes ___No ___Sometimes
What do you typically eat for breakfast? _______________________________________________________
_______________________________________________________________________________________
Do you eat lunch? ____ Yes ___No ___Sometimes
What do you typically eat for lunch? _________________________________________________________
______________________________________________________________________________________
Do you eat dinner? ___Yes ___No ____Sometimes
What do you typically eat for dinner? _________________________________________________________
_______________________________________________________________________________________
What snacks do you typically eat, how often and how much? ______________________________________
How many ounces of water do you consume daily? _____________________________________________
How many fruits do you eat daily? ____________________
How many vegetables do you eat daily? _______________
How many dairy products do you eat daily? _____________
Do you eat or drink anything that is low fat, low salt, reduced fat, contains artificial sweeteners? ______________
How many bowel movements do you have daily? _______
Are they black, green, dark, medium, light or clay colored? _________________________________________
How are they shaped? Long and narrow, small and pebble-like, small pieces, long and tube shaped, loose, or in pieces? ______________________________________________________________________________

Case History
How would you rate your current level of stress? __________________________________________________
What are your stressors in your life? ____________________________________________________________
What were your past stressors? _______________________________________________________________
What do you do to alleviate your stress? ________________________________________________________
How long does it last? _______________________________________________________________________
How do you know if you are recovering from your stress? ___________________________________________
When you are experiencing mild, moderate or severe stress do you notice any physical signs? Anxiety, depression, addictive behaviors, irritability, withdrawn, low energy, digestive problems, change in vision, headaches, muscle tension, constipation, diarrhea, or other symptoms?___________________________________________
__________________________________________________________________________________________
Do you have a racing mind? __________________________________________________________________
Does your stress interfere with your ability to sleep? ________________________________________________
Do you meditate? ___________________________
What are your healthy habits that you engage in regularly? ___________________________________________
__________________________________________________________________________________________
What are your unhealthy habits that you engage in? How often? _______________________________________
__________________________________________________________________________________________
How would you rate your current energy level? ____________________________________________________
What was your energy level like 1, 3 and 5 years ago? Has anything happened in your life that you attribute to it?
_________________________________________________________________________________________
_________________________________________________________________________________________
Date of last annual physical: _______________________________________________________________
Any other testing or exams you have had within the past three years? _________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Any other health issues that were not mentioned above?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
What are your top three health goals?
1. _______________________________________________________________________________
2. _______________________________________________________________________________
3. _______________________________________________________________________________
How would you like to receive appointment reminders? _____ Email _____ Text
Email: ____________________________________________ (provide best email if not on page 1)
Text: ______________________________ (provide your cell phone carrier – Verizon, AT&T, Sprint…)