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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

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