Gabel Chiropractic

PATIENT CASE HISTORY

 

Name: ___________________________          Date: ___________________      Sex: ____ DOB: __________

SS#: ___________________

Address: _________________________________________               City: _____________________      State: ____ Zip: _________

Home Phone: ________________  email address: ________________________________________________________________

Employer:  ________________________    Work Phone: ____________________

Referred By: _______________________   Marital Status: M  S  W  D                 Spouse’s Name: __________________________________

CHIEF COMPLAINT/REASON FOR THIS APPOINTMENT:

  1. ____________________________________________________________________________________________________________

Additional problems or concerns you would like to address:

  1. ____________________________________________________________________________________________________________
  2. ____________________________________________________________________________________________________________

What treatment have you already had for these conditions:

___________________________________________________________________________________________________________________

Were x-rays taken?  If yes, where?

___________________________________________________________________________________________________________________

Is this condition due to a:   □Auto Accident     □ Work Injury        □Other Accident             □ Illness                 □ Unknown

□ Other ____________________________________________________________________________________________________________

How long have you had this complaint? __________________________________________________________________________________

Circle the intensity of pain:                (0 = no pain, 10 = worst pain)             0    1    2    3    4    5    6    7    8    9    10

Are symptoms generally…   Improving           Getting Worse        About the Same           Intermittent (comes & goes)

Does this pain radiate or travel to a different area of the body?  □ No       □ Yes, it travels ____________________________________________

Have you had similar symptoms before?         □ No       □ Yes      When? __________________________________________________________

Have you lost time from work?          □ No       □ Yes      Dates lost: _______________________________________________________________

Date returned to work: ________________________               Dr. Ordered?         □ No       □ Yes      Self Determined?  □ No       □ Yes

Effect on Daily Activities?                   No Effect             Extra Effort Required         Occasional Limitation       Frequent or Severe Limitation

 

 

PAST MEDICAL HISORY                                                                                SOCIAL HISTORY

Aids, HIV              Alcoholism            Allergy                                                   Education Level Completed: __________________________________

Arthritis                 Asthma                  Cancer                                                    Children (list ages):  ________________________________________

Cholesterol            Depression            Diabetes                                                                Major Stress in the last 6 months? _____________________________

Epilepsy                 Heart Disease       Hepatitis                                                _________________________________________________________

Herniated Disk      Pacemaker             Pinched Nerve

Thyroid                  Tuberculosis         Tumors

High Blood Pressure                                                                                           YOUR HEALTH CARE TEAM

                                                                                                                                Family Physician: _______________________ Phone: ____________

Other Illnesses: _____________________________                                                Other Specialist:   _______________________ Phone: ____________

__________________________________________                                              Have you ever seen:

Surgery: ___________________________________                                                Chiropractor                     Name: ______________________________ __________________________________________                                         Acupuncture                    Name: ______________________________ Other Injuries/accidents: ______________________                                               Massage therapist               Name: ______________________________

 

 

 

LIFE STYLE / SELF-CARE ISSUES                                                                DIET HABITS

Have you smoked cigarettes?            □ Yes      □ No                                       Breakfast: ________________________________________________

___ packs/day, smoked for ___ years                                                             Lunch:       ________________________________________________

Do you still smoke?             □ Yes      □ No                                                       Dinner:      ________________________________________________

Do you drink caffeinated beverages?  □ Yes  □ No                                       Snacks:     ________________________________________________

___ cups, cans/day                                                                                             Fluids:       cups of water _____        other fluids _____

Do you drink alcohol?         □ Yes      □ No                                                      

___ number of drinks/week                                                                                CURRENT MEDICTIONS                 Dosage  Times/day

Do you exercise regularly? □ Yes      □ No                                                       _______________________                          ______  _________

Type, Frequency ___________________________                                  _______________________                          ______  _________

Do you sleep soundly?       □ Yes      □ No                                                       _______________________                          ______  _________

Is your diet healthy enough?   □ Yes               □ No                                      CURRENT HERBS/ VITAMINS                      Dosage  Times/day               

                                                        Not Sure       Need Help                         _______________________                          ______  _________

                                                                                                                                _______________________                          ______  _________

                                                                                                                                _______________________                          ______  _________

 

 

REVIEW OF SYSTEMS:

Please check areas of concern.

 

Constitutional                      Ears, Nose, Mouth, Throat                 Digestion and Intestines                    Urine, Kidneys, Bladder

___ decreased sleep            ___ ringing ears                                                   ___ indigestion                                    ___ decreased urine flow

___ irregular sleep               ___ nose bleeds                                                   ___ belching                                         ___ blood or pus in urine

___ excessive sleep             ___ postnasal drip                                               ___ difficulty swallowing                   ___ painful urination

___ poor appetite                                ___ sinus problems                                             ___ heartburn                                       ___ wake up to urinate

___ fever                               ___ trouble with taste/smell                               ___ nausea                                           ___ kidney stones

___ chills                               ___ poor hearing                                                 ___ liver trouble                                   ___ loss of control of urine

___ weight loss                    ___ earaches                                                        ___ vomiting                                        ___ sudden urges to urinate

___ weight gain                   ___ headaches                                                     ___ blood in stools                             ___ frequent urination

___ fatigue                            ___ facial pain                                                      ___ diarrhea                                         

                                                ___ jaw clicks                                                       ___ foods that upset your system    Women’s Reproductive

Immune System                   ___ grinding teeth                                               __________________________   ___ age period started

___ too many infections     ___ sore throat                                                     ___ cramping bowels                          ___ number of pregnancies

___ allergies to food or       ___ mouth sores                                                  ___constipation                                   ___ pregnancies lost

        environment                                                                                                                                                                  ___ past fertility problems

___ other concerns             Eyes                                                                        Nerves, movement, brain                    ___ number of live births

                                                ___ eye pain                                                         ___ seizures                                          ___ children currently living

Mood, Thoughts, and           ___ blurred vision                                               ___ nerve pains                                   ___ age period stopped, menopause

Emotions                               ___ poor vision __day __night                        ___ poor balance                                

___ manic episodes             ___ wear corrective lenses                                 ___ poor coordination                        Sexual Organs

___ energy problems          ___ near sighted                                                  ___ tremors or shaking                       ___ erection problems

___ depression                    ___ far sighted                                                     ___ numbness                                      ___ infertility

___ panic attacks                                                                                                 ___ dizziness                                        ___ repeated infections

___ anxiety, over stressed Heart & Circulation                                           ___ poor memory                                 Women:

                                                ___ chest pain                                                      ___ trouble sleeping                           ___ pelvic pain

Skin, Hair, Breast              ___ lightheadedness                                                                                                           ___ vaginal discharge

___ breast lumps or pain    ___ palpitations                                                   Muscles, Bones & joints                   ___ painful periods

___ breast leaks fluid          ___ cold hands/feet                                            ___neck pain                                        ___ premenstrual syndrome

___ rashes                            ___ fainting                                                          ___ back pain                                       ___ hot flashes

___ itching, hives                                ___ swelling feet                                                  ___ muscle pain                                   ___ itching or soreness

___ hair loss                         ___blood clots                                                     ___ muscle weakness                        

___ mole changes                ___ varicose veins                                              ___ muscle cramps                             

___ dry skin, eczema                                                                                           ___ joint swelling

                                                                                                                                ___ painful joints

                                                                                                                                                ___ shoulder ___ elbow

                                                                                                                                                ___ hip     ___ knee ___ ankle

                                                                                                                                                ___ foot     ___toe     ___ hand

                                                                                                                                                ___ wrist    ___ fingers