All-Health Chiropractic
SINCE 1997
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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! "