Chiropractic Case History Form (Page 2 of 2) in pdf

Please mark each item below for each sign or symptom you presently have or previously had:

GENERAL SYMPTOMS

EAR/NOSE/THROAT

RESPIRATORY

__ Convulsions

__ Earache

__ Asthma

__ Dizziness

__ Ear Noises

__ Chronic Cough

__ Fainting

__ Enlarged Thyroid

__ Difficulty Breathing

__ Headache

__ Frequent Colds

__ Spitting Blood

__ Nervousness

__ Hay Fever

__ Spitting Phlegm

__ Numbness

__ Nasal Blockage

GENITO-URINARY

__ Wheezing

__ Nose Bleeds

__ Blood in Urine

__ Pain Behind Eyes

__ Frequent Urination

MUSCLES & JOINTS

__ Low Back Problems

__ Poor Vision

__ Kidney Infection

__ Pain between Shoulders

__ Sinusitis

__ Painful Urination

__ Neck Problems

__ Sore Throats

__ Prostate Problems

__ Arm Problems

__ Tonsillitis

__ Loss of Bladder Control

__ Leg Problems

GASTRO-INTESTINAL

SKIN OR ALLERGIES

__ Swollen Joints

__ Belching/Gas

__ Boils

__ Painful Joints

__ Colon Problems

__ Bruising Easily

__ Stiff Joints

__ Constipation

__ Dryness

__ Sore Muscles

__ Diarrhea

__ Eczema/Rash/Dermatitis

__ Weak Muscles

__ Excessive Hunger

__ Hives

__ Walking Problems

__ Excessive Thirst

__ Itching

__ Sprains/Strains

__ Gall Bladder Trouble

__ Sensitive Skin

__ Broken Bones

__ Hemorrhoids

__ Allergy ______________

CARDIO-VASCULAR

__ Liver/Gallbladder

FOR WOMEN ONLY

__ High Blood Pressure

__ Nausea

__ Birth Control _________

__ Heart Attack

__ Abdominal Pain

__ Hormone Replacement

__ Pain over Heart

__ Ulcer

__ Cramps/Backaches

__ Poor Circulation

__ Poor Appetite

__ Excessive Flow

__ Heart Trouble

__ Poor Digestion

__ Hot Flashes

__ Rapid Heart

__ Vomiting

__ Irregular Cycle

__ Slow Heart

__ Vomiting Blood

__ Miscarriage

__ Strokes

__ Black Stool

__ Painful Periods

__ Swelling Ankles

__ Bloody Stool

__ Vaginal Discharge

__ Varicose Veins

__ Weight Loss/Gain

__ Breast Pain

Pregnant at this Time Y/N

I hereby certify that the statements and answers given on this form are accurate to the best of knowledge and

understand it is my responsibility to inform this office of any changes in my health.

I agree to allow this office to examine me for further evaluation.

Patient

Signature______________________________________________________Date__________________________

Chiropractic Case History Form Page 2

Related Articles

Related forms

Related Categories