Case History

case
history
PREPARED FOR:
___________________________
ABOUT YOUR HEALTH ABOUT YOUR CARE
The human body is designed to be healthy. Throughout life, events Chiropractic provides three types of care. The first is Conditioned
occur which damage your health expression. This case history will Based Care, which corrects the most recent layer of Spinal and
uncover the layers of damage, especially to your nerve system, that Neurological damage (VSC). This care usually reduces or eliminates
have resulted in poor health. Following your exam, your chiropractor the symptoms. Then begins Corrective Care, which corrects the years
will outline a course of care to begin to correct these layers of damage of damage that occurred when there were few symptoms. And finally,
and recover your innate health potential. Chiropractic offers a genuine approach to Wellness Care. All of these
options will be explained at your report of findings. Then you’ll be
able to begin a course of care that fits your health goals.
LOSS OF WELLNESS (BIRTH-AGE 5)

At birth, when your nerve system is first damaged, your wellness begins to decrease and the journey to ill health starts.
Patient Comment Chiropractor’s Comments

Yes No 1. Pregnancy (if answer is yes)
Did your mother:
  Smoke or drink alcohol? __________________________ __________________________
  Have a proper diet? __________________________ __________________________
  Exercise through her pregnancy? __________________________ __________________________
  Experience any falls and injuries during pregnancy? __________________________ __________________________
  Experience any physical and/or mental abuse? __________________________ __________________________
2. Birth Process
  Was the delivery long? __________________________ __________________________
  Was the delivery difficult? __________________________ __________________________
  Forceps? __________________________ __________________________
  Caesarean? __________________________ __________________________
  Breach/cephalic? __________________________ __________________________
  Home Birth? __________________________ __________________________
  Hospital Birth? __________________________ __________________________
  Mother given drugs during delivery? __________________________ __________________________
  Was labor induced? __________________________ __________________________
3. Growth and Development

  Were you taught how to care for your spine? __________________________ __________________________
  Did you roll out of bed? __________________________ __________________________
  Were you a headbanger or rocker? __________________________ __________________________
  Were you breastfed? __________________________ __________________________
  Childhood sicknesses? __________________________ __________________________
  Accidents? __________________________ __________________________
  Surgery? __________________________ __________________________
  Drugs? __________________________ __________________________
  Did you fall while learning to walk? __________________________ __________________________
  Were you picked on by siblings? __________________________ __________________________
  Child abuse? __________________________ __________________________
  Spanking (how?) __________________________ __________________________
  Pulled ear/chin? __________________________ __________________________
  Other __________________________ __________________________
  Chair pulled out when sat down? __________________________ __________________________
  Did you fall down stairs? __________________________ __________________________
  Were you yanked by your arm? __________________________ __________________________
  Did you have other traumas? What? When? __________________________ __________________________
LOSS OF WHOLE BODY HEALTH (AGE 5-PRESENT)
As layers of damage increased, you probably began to experience symptoms and random bouts of sickness.
Patient Comment Chiropractor’s Comments

(if answer is yes)
Yes No
  Were you taught proper body movement and care? __________________________ __________________________
  Did/do you smoke? __________________________ __________________________
  Did/do you drink any alcohol? __________________________ __________________________
  Diet (Do you eat healthy foods?) __________________________ __________________________
  Have you ever been in accidents? __________________________ __________________________
  Have you had surgery and organs removed/replaced? __________________________ __________________________
  Drugs? (Prescriptive or non-prescriptive) __________________________ __________________________
  Teeth problems? __________________________ __________________________
  Eye problems? __________________________ __________________________
  Hearing problems? __________________________ __________________________
  Exercise regularly? __________________________ __________________________
  Sleeping habits (nightmares?) __________________________ __________________________
  Did/do you have occupational stress? __________________________ __________________________
  Physical stress? __________________________ __________________________
  Mental stress? __________________________ __________________________
  Hobbies/Sports injuries? __________________________ __________________________
  Other traumas or problems? __________________________ __________________________
SYMPTOMS & ILL HEALTH (PRESENT STATE OF ILL HEALTH)

Years of untreated damage showed up as acute or chronic symptoms.
Other Symptoms:
 Headaches  Face Flushed  Lights Bother Eyes  Hands Cold
 Neck Pain  Neck Stiff  Loss of Memory  Stomach Upset
 Sleeping Problems  Pins & Needles in Legs  Ears Ring  Constipation
 Back Pain  Pins & Needles in Arms  Fever  Cold Sweats
 Nervousness  Numbness in Fingers  Fainting  Loss of Balance
 Tension  Numbness in Toes  Loss of Smell  Buzzing in Ears
 Irritability  Shortness of Breath  Loss of Taste
 Chest Pain  Fatigue  Diarrhea
 Dizziness  Depression  Feet Cold
PRESENT COMPLAINT
Major complaint: ________________________________________________________________________________________________________
Pain or problem started when: _____________________________________________________________________________________________
Pains are:  Sharp  Dull  Constant  Intermittent Is condition getting progressively worse?  Yes  No
What activities aggravate your condition/pain? _______________________________________________________________________________
Is condition worse during certain times of the day?  Yes  No If so when? ________________________________________________
Is this condition interfering with (circle those that apply): Work? Sleep? Routine? Other: ____________________________________
Other doctors seen for this condition: _______________________________________________________________________________________
Any home remedies? _____________________________________________________________________________________________________

SYMPTOMS & ILL HEALTH (CONT’D)
Have you been under drug and medical care?  Yes  No
If yes, please explain: _____________________________________________________________________________________________________
What medications are you taking? _________________________________________________ How long? _____________________________
Have you had surgery?  Yes  No
For what? _________________________________________________ FAMILY HISTORY

When? ___________________________________________________
Father's side Mother’s side
What side effects (if any) did you experience from drugs and surgery?  Heart Disease  Heart Disease
__________________________________________________________  Arthritis  Arthritis
 Cancer  Cancer
__________________________________________________________
 Diabetes  Diabetes
__________________________________________________________  Other: __________________  Other: __________________
PATIENT INFORMATION
Name: _________________________________________________ Social Security #: _______________________ Date: __________________
Gender:  Male  Female Date of birth: ____________ (Age: _______ ) If you were referred, by whom? _______________________
Address: _____________________________________________________ City: ________________________ State: _____ Zip: __________
Home Phone: ___________________________ Work Phone: ____________________________ Cell Phone: ____________________________
Occupation: _____________________________________________________ Employer: ____________________________________________
Marital status: S M D W Spouse’s Name and Occupation: ____________________________________________________________________
Number of Children and Ages: _____________________________________________________________________________________________
Have you ever recieved Chiropractic care?  Yes  No
Have you ever been in an accident?  Yes  No  Work  Auto  Other: ___________________________________________
Nature of accident: __________________________________________________________ When: _____________________________________
Did you require post-accident hospitalization?  Yes  No
Did you lose days at work as a result?  Yes  No How many? ____________________________________________________________
Is insurance involved?  Yes  No Which company? ____________________________________________________________________
Attorney’s name  n/a ____________________________________________ Claim #: ____________________________________________
Comments (office use only): ________________________________________________________________________________________________

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case

LOSS OF WELLNESS (BIRTH-AGE 5)

Patient Comment Chiropractor’s Comments

3. Growth and Development

Patient Comment Chiropractor’s Comments

SYMPTOMS & ILL HEALTH (PRESENT STATE OF ILL HEALTH)

Pain or problem started when: _____________________________________________________________________________________________

What activities aggravate your condition/pain? _______________________________________________________________________________

Other doctors seen for this condition: _______________________________________________________________________________________

Any home remedies? _____________________________________________________________________________________________________

If yes, please explain: _____________________________________________________________________________________________________

What medications are you taking? _________________________________________________ How long? _____________________________

Have you had surgery?  Yes  No

For what? _________________________________________________ FAMILY HISTORY

Address: _____________________________________________________ City: ________________________ State: _____ Zip: __________

Home Phone: ___________________________ Work Phone: ____________________________ Cell Phone: ____________________________

Occupation: _____________________________________________________ Employer: ____________________________________________

Marital status: S M D W Spouse’s Name and Occupation: ____________________________________________________________________

Number of Children and Ages: _____________________________________________________________________________________________

Have you ever recieved Chiropractic care?  Yes  No

Nature of accident: __________________________________________________________ When: _____________________________________

Did you require post-accident hospitalization?  Yes  No

Is insurance involved?  Yes  No Which company? ____________________________________________________________________

Attorney’s name  n/a ____________________________________________ Claim #: ____________________________________________

Comments (office use only): ________________________________________________________________________________________________

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What medications are you taking? _____________________ How long? _

Address: _______________________________ City: State: _ Zip: ________

Home Phone: _ Work Phone: Cell Phone: __

Occupation: _________ Employer:

Nature of accident: ______________________ When: _

Attorney’s name  n/a Claim #: