Chirpractic_physical_therapy_form





































































CONFIDENTIAL PATIENT CASE HISTORY
date
social security number
drivers license number
name
address
city
state
zip
home phone
cell phone
birth date
age
sex
business or employer
type of work
business address and phone number
check one
number of children
name and number of emergency contact
spouse name
occupation
employer
who is responsible for your bill
other


CURRENT HEALTH CONDITION
purpose of this appointment
other doctors seen for this condition
when did this condition begin
check
medication you now take
others


PAST HEALTH HISTORY
major surgery or operations
otherone
major accidents or falls
hospitalization if other than above
previous chiropractic care
doctors name
appox date of last visit


































































Indicate ability to perform the following activities:
coughing or sneezing
climbing
getting in and out of a car
kneeling
bending forward to brush teeth
balancing
turing over in bed
dressing self
walking short distance
sleeping
standing more than one hour
stooping
sitting at table
gripping
lying on back
pushing
lying flat on stomach
pulling
lying on side with knees bent
reaching
bending over forward
sexual activity
checking symptoms of nervous syatems
how often do you have headaches
symptoms are better in
symptoms are worse in
symptoms do not change with time of day

For woman only
are you pregnant
date of onset of last menstrual cycle
give date of last xray
what body part were they taken of
Family History:
cancer
diabetes
heart problems
back or neck problems














































Accident Information
have you retained an attorney
 
If yes  
attorney name
attorney address
attorney phone
 
number of people in vechicle and their name
were the policy notified
what direction were you headed
what direction was other vechicle
name of street or town
were you struck from
in your own words please describe accident
please complaints and symptoms
did you lose any time from work
date when you lose from work
type of employment
where were you taken immediately following accident
if taken to the hospital did you
have you ever been involved in an accident before