Chiropractic Case History
Name ___________________________________________ Date _______________________
Home Phone ___________________ Cell ____________ Email _________________________
Address _____________________________________________________________________
Age ___________ Date of Birth ________________ Marital: S M W D Children ____________
Occupation _______________________ Employer ___________________________________
Address _____________________________________________________________________
Student at ______________________________ Full Time ____________ Part Time ________
Name of Spouse ________________________________ Occupation _____________________
Employer _________________________________ Phone ____________________________
Purpose of Appointment _________________________________________________________
Other Doctors seen for this Condition _______________________________________________
Is the condition due to an employment injury or illness? ________________________________
Is the condition due to auto accident injury or other accident? ____________________________
Number of Days lost from work ___________________________________________________
Date symptoms appeared/accident happened _______________________________________
Have you ever had a similar condition? _____________________ When & Please describe ____________________________________________________________________________
Have you ever suffered any of the following?
Dizziness ______ Arthritis _____ Digestive Disorder _____ Backaches _____ Hernia _______
Headaches ______ Nervousness _____ Heart Trouble _____ Numbness _____ Cancer ______
Sinus Trouble _____ Diabetes _____ Asthma _____ Rheumatic Fever ______ Neuritis ______
Do you have a pacemaker or defibrillator? ___________ Date of last physical exam _________
Primary Physician _____________________________________________________________
Describe any recent conditions ___________________________________________________
I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myselg. I undrstand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional srvices rendered to me will be immediately due and payable. _____________ Initials.
I have reviewed a copy of the HIPPA Notice of Privacy Practices Policy. I understand the policy and I will adhere to the policy set forth by BACKBONE OF HEALTHCARE.
_________________________________ _________________________
Patient of Signature or Guardian Signature Date Signed
_________________________________ ________________________
Patient Name Relationship