ALL HEALTH CHIROPRACTIC, INC       (330) 468 - 2555      9425 Olde Eight Rd, Northfield Center, Ohio 

                                                                                                                                                                     CASE #______________

                                                                                               DATE_______________

NAME____________________________________________________SOCIAL SECURITY #___________________________ ADDRESS________________________CITY________________________STATE_____________ZIP CODE_______________

CELL PHONE #___________________________________HOME/WORK PHONE#___________________________________

DATE OF BIRTH___________________________AGE_______ M_____F_____ AGE OF CHILDREN______________________

EMPLOYER NAME & ADDRESS________________________________________________OCCUPATION__________________

HEALTH INSURANCE COMPANY________________________________POLICY #___________________________________

IF YOU ARE COVERED BY A SPOUSE OR PARENT’S INSURANCE PLAN PLEASE PROVIDE THE BELOW INFORMATION:

SPOUSE NAME__________________________ EMPLOYER & ADDRESS___________________________________________

SPOUSE  DATE OF BIRTH___________________________SPOUSE SOCIAL SECURITY #_______________________________

SPOUSE OCCUPATION________________SPOUSE CELL #___________________WORK PHONE#_______________________

 

PERSON TO CALL IN CASE OF AN EMERGENCY___________________________PHONE #_____________________________

                                                            RELATION______________________________2ND PHONE #___________________________

 

HOW DID YOU FIND OUT ABOUT OUR OFFICE?  Friend/Family____________________ Website_______Newspaper____________

 

 

 

PAST AND PRESENT GENERAL HISTORY:

Cardio-Vascular Signs______ Ears, Eyes, Nose & Throat____________ Family Diseases____________________________ Gastro-Intestinal Problems_______________ Genito-Urinary Symptoms_______  Habits__________________________ Muscle& Joint Symptoms__________ Respiratory  Problems________________ Skin Problems_____________________

 

LIST ANY OPERATIONS________________________________________________________________________________

 

PLEASE CIRCLE ANY AREAS OF PAIN OR NUMBNESS ACCORDING TO THE BODY BELOW:

                                                                                                                                                                                                                                

HEAD                   Pain                      Numbness                          Right                     Left

NECK                    Pain                      Numbness                          Right                     Left

SHOULDER        Pain                      Numbness                          Right                     Left

ELBOW                Pain                      Numbness                          Right                     Left

WRIST                  Pain                      Numbness                          Right                     Left

HAND                   Pain                      Numbness                          Right                     Left

FINGERS             Pain                      Numbness                          Right                     Left

MID BACK           Pain                      Numbness                          Right                     Left

LOW BACK          Pain                      Numbness                          Right                     Left

HIP                        Pain                      Numbness                          Right                     Left

THIGH                  Pain                      Numbness                          Right                     Left

KNEE                    Pain                      Numbness                          Right                     Left

CALF                     Pain                      Numbness                          Right                     Left

ANKLE                 Pain                      Numbness                          Right                     Left

FOOT                    Pain                      Numbness                          Right                     Left

TOES                     Pain                      Numbness                          Right                     Left       

 

CURRENT PROBLEM

WHAT IS THE MAIN HEALTH CONDITION YOU WANT TO TALK TO THE DOCTOR ABOUT?___________________________

__________________________________________________________________________________________________

 

HOW LONG HAVE YOU HAD THIS CONDITION/SYMPTOM?___________________________________________________

WHAT ACTIVITIES AGGRAVATE YOUR CONDITION?_________________________________________________________

IS THE CONDITION GETTING WORSE?_______YES ________NO   EPISODES PER DAY _______ WEEK_______ MO_______

CONDITION INTERFERES WITH: WORK _______  SLEEP_______ DAILY ROUTINE _______ OTHER____________________ __________________________________________________________________________________________________

 

DRUGS TAKING CURRENTLY:

Nerve Pills _____  Pain Killers _____ Muscle Relaxers ______  Tranquilizers ______ None________ Other ____________

OTHER____________________________________________________________________________________________

MEDICATION

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

 

HAVE YOU EVER:                                            YES         NO         DESCRIBE BRIEFLY:

Been Knocked Unconscious?                       o  o   ____________________________________________________

Treated for a Spine or Nerve Disorder?     o  o   ____________________________________________________

Used a Cane, Crutch or Other Support?    o  o   ____________________________________________________

Had any Fractures or Dislocations?           o  o   ____________________________________________________

Had any Accidents or Falls?                         o  o   ____________________________________________________

Been Hospitalized other than Surgery?     o  o   ____________________________________________________

 

Does Any Member of Your Family Have the Following? (please circle)

 

Arthritis     Abnormal Spinal Development     Cancer    Diabetes      Epilepsy     Emotional Problems      Intestinal Disorders

Lung Disease     Neck or Back Pains     Scoliosis     Spinal Arthritis     Other Health Problems?________________________ 

 

If Yes:                   Father                  Mother                Brother                Sister                    Grandparent                      Uncle/Aunt

 

PREVIOUS MEDICAL CARE FOR PRIMARY COMPLAINT

Name and Location of Doctor__________________________________________________ Date Seen_______________ 

Hospital__________________________________ Examinations/ X-Rays/MRIs__________________________________

Condition or Diagnosis_______________________________________ Type of Treatment_________________________

Duration of Treatment____________________________ Results of Treatment:  Good _______       Fair ______  Poor_____

 

PREVIOUS CHIROPRACTIC CARE

Name and Location of Doctor_________________________________________ Date of Last Spine Exam _____________

Condition, Symptom or Diagnosis_______________________________________ X-Rays Taken_____________________

How often Treated_________ Type of Treatment ________________________ How long was each visit______________ 

Length of Time Treated for Condition:    Days__________  Weeks ____________  Months __________ Year___________

Results of Treatment:      Good_____________      Fair _____________        Poor _____________

 

PLEASE SELECT THE TYPE OF PATIENT CARE DESIRED FOR YOUR CURRENT SYMPTOMS AND CONDITION:

o  RELIEF CARE                o  CORRECTIVE CARE                    o  COMPREHENSIVE CARE           o  Prefer Doctors Opinion

I CERTIFY THAT ALL INFORMATION GIVEN IS TRUE AND CORRECT. I hereby authorize the release of any information required by this office.  I also authorize my benefit payments to be made directly to this clinic.  I understand that I am financially responsible for all services rendered.  All X-Rays are the property of ALL HEALTH CHIROPRACTIC, INC.

 

                                                                                                         ____________________________________________________

                                                                                                                        SIGNATURE OF PATIENT OR GUARDIAN

 

 

 

 

" Feel Better, Live Better...Naturally! "

All-Health Chiropractic

9425 Olde Eight Road #1

Northfield, OH 44067

(330) 468-2555