CASE HISTORY (FORM CH2017)
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 answer
Your Full Name *
Your answer
Your Date of Birth *
Your answer
Age *
Your answer
Gender *
"Male" or "Female"
Your answer
Address / City / State / Zip *
Your answer
Best Contact Phone # *
Your answer
Work Phone # *
Your answer
Email *
Your answer
Race: *
White, Black, Native American, Asian, Other, Unknown
Your answer
Ethnicity *
"Hispanic" or "Non-Hispanic"
Your answer
Marital Status: *
Single, Married, Widowed, Divorced, Separated
Your answer
Occupation: *
What do you do for work?
Your answer
Emergency Contact Name
Your answer
Emergency Contact Phone #
Your answer
Emergency Contact Relationship
Your answer
What insurance carrier do you use? *
(Put "None" if not using insurance)
Your answer
How many children do you have?
Your answer
Full Name of Spouse or Guardian?
Your answer
Smoking Status
(Current Daily, Current Some Days, Former, Never)
Your answer
Please list current medications with dosages:
Your answer
Please list current medications with dosages:
Your answer
Please list any medication allergies:
Your answer
What Is Your Main Complaint Today? *
Your answer
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
Your answer
Please list any health conditions/surgeries you have been treated for in the last year:
Your answer
Please explain any previous serious illness:
Your answer
Is there anyone in your family history with Heart Disease? If "Yes", please list relationship to you. If none, write "None".
Your answer
Is there anyone in your family history with Cancer? If "Yes", please list relationship to you. If none, write "None".
Your answer
Is there anyone in your family history with Diabetes? If "Yes", please list relationship to you. If none, write "None".
Your answer
Is there anyone in your family history with Back Problems? If "Yes", please list relationship to you. If none, write "None".
Your answer
Is there anyone in your family history with Disc Problems? If "Yes", please list relationship to you. If none, write "None".
Your answer
Is there anyone in your family history with Arthritis? If "Yes", please list relationship to you. If none, write "None".
Your answer
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]
Your answer
If you suffer/ed from ANY of the above, please briefly explain:
Your answer
Question X-ray Purposes For Females Only: Are you possibly pregnant? ("Yes" or "No")
Your answer
Whom may we thank for referring you to our office?
Your answer
Next
Never submit passwords through Google Forms.
This form was created inside of Lovett Chiropractic and Pain Relief Clinic. Report Abuse - Terms of Service