CASE HISTORY (FORM CH2017)

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There are 36 questions. Scroll down to fill in each question and press "SUBMIT" at the end. Voila! You will save 15 mins at your office visit!

Today's Date *

Your Full Name *

Your Date of Birth *

Age *

Gender *

"Male" or "Female"

Address / City / State / Zip *

Best Contact Phone # *

Work Phone # *

Email *

Race: *

White, Black, Native American, Asian, Other, Unknown

Ethnicity *

"Hispanic" or "Non-Hispanic"

Marital Status: *

Single, Married, Widowed, Divorced, Separated

Occupation: *

What do you do for work?

Emergency Contact Name

Emergency Contact Phone #

Emergency Contact Relationship

What insurance carrier do you use? *

(Put "None" if not using insurance)

How many children do you have?

Full Name of Spouse or Guardian?

Smoking Status

(Current Daily, Current Some Days, Former, Never)

Please list current medications with dosages:

Please list any medication allergies:

What Is Your Main Complaint Today? *

Please list ANY OTHER symptoms you're having NOW:

Headaches, Dizziness, Sleeping Problems, Buzzing in Ears, Fainting, Neck Pain, Neck Stiffness, Head Feels Heavy, Feet Cold, Nervousness, Loss of Smell, Face Flushed, Hands Cold, Loss of Taste, Cold Sweats, Back Pain, Depression, Loss of Memory, Lights Bother Eyes, Ears Ring, Tension, Fatigue, Shortness of Breath, Loss of Balance, Diarrhea, Irritability, Fever, Numb in Fingers, Pins/Needles in Arms, Chest Pain, Constipation, Stomach Upset, Pins/Needles in Legs/Toes

Please list any health conditions/surgeries you have been treated for in the last year:

Please explain any previous serious illness:

Is there anyone in your family history with Heart Disease? If "Yes", please list relationship to you. If none, write "None".

Is there anyone in your family history with Cancer? If "Yes", please list relationship to you. If none, write "None".

Is there anyone in your family history with Diabetes? If "Yes", please list relationship to you. If none, write "None".

Is there anyone in your family history with Back Problems? If "Yes", please list relationship to you. If none, write "None".

Is there anyone in your family history with Disc Problems? If "Yes", please list relationship to you. If none, write "None".

Is there anyone in your family history with Arthritis? If "Yes", please list relationship to you. If none, write "None".

Please list ALL of the following you have EVER suffered from: [Dizziness, Arthritis, Neuritis, Backaches, Headaches, Digestive Disorders, Heart Trouble, Numbness, Nervousness, Diabetes, Lung Problems, Sinus Trouble, Tuberculosis, Anemia, Rheumatic Fever, Cancer, Kidney Trouble]

If you suffer/ed from ANY of the above, please briefly explain:

Question X-ray Purposes For Females Only: Are you possibly pregnant? ("Yes" or "No")

Whom may we thank for referring you to our office?

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