Quickcharts Patient Case History Template printable pdf download

QUICKCHARTS PATIENT CASE HISTORY

Name: ____________________________________ Date of Birth: ________________________

Address: _______________________________________________________________________

City: ___________________________ State: ____________ Zip: _________________________

Home Phone: ______-______-_______Work Phone: ______-______-_______

Cell Phone: ______-______-___________ Email Address: _______________________________

Marital Status:

S M W D

Referred by: _______________________________

Social Security #: _______-______-_______ Gender: Male - Female Pregnant? Yes - No

Ever had chiropractic care? No yes When? ___________Why? __________ Where?__________

Race:

Ethnicity:

□ American Indian

□Nat. Hawaiian/Pacific Islander

□Declined

□Asian

□ Other: __________________

□Hispanic or Latino

□African American □Caucasian

□ Other: ________________

□Declined

List any Allergies:

□Animals □Aspirin □Bees □Chocolate □Dairy □Dust □Eggs □Latex □Molds □Penicillin

□Ragweed/Pollen □Rubber □Seasonal Allergies □Shellfish □Soaps □Wheat □X-Ray Dye

□ Other: ____________________________

List any Surgeries:

□Back □Brain □Elbow □Foot □Hip □Knee □Neck □Neurological □Shoulder □Wrist

□Other: ______________

List ALL Past Medical History conditions:

□Ankle Pain □Arm Pain □Arthritis □Asthma □Back Pain □Broken Bones □Cancer □Chest Pain

□Depression □Diabetes □Dizziness □Elbow Pain □Epilepsy □Eye/Vision Problems □Fainting □Fatigue

□Foot Pain □Genetic Spinal Condition □Hand Pain □Headaches □Hearing Problems □Hepatitis

□High Blood Pressure □Hip Pain □HIV □Jaw Pain □Joint Stiffness □Knee Pain □Leg Pain

□Menstrual Problems □Mid-Back Pain □Minor Heart Problem □Multiple Sclerosis □Neck Pain

□Neurological Problems □Pacemaker □Parkinson's □Polio □Prostate Problems □Shoulder Pain

□Significant Weight Change □Spinal Cord Injury □Sprain/Strain □Stroke/Heart Attack

□Other: _______________________________________________________________

List Type of Medications you are taking:

□Anxiety □Muscle Relaxors □Pain Killers □Insulin □Birth control □Cardiovascular □Allergy □Seizure

□Other: _________________________________

List your Family History:

□Arthritis □ Asthma □Back Pain □ Cancer □ Depression □Diabetes □ Epilepsy □Genetic Spinal Condition

□High Blood Pressure □Heart Problems □Multiple Sclerosis □Neurological Problems □Parkinson’s

□Polio □ Prostate Problems □Stroke/Heart Attack □Other: ________________________

Quickcharts Patient Case History Template

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