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Detailed Chiropractic Case History

Name: _____________________                     Date:_______________

History

Patient Clinical Profile
Age_______  Gender:[M] [F] Occupation:_____________________

1. Reason for seeking chiropractic care:
    Primary reason:_____________________________________________________
    Secondary reason:___________________________________________________
    Other factors contributing to the primary and secondary reason:
    _________________________________________________________________

2. Chief complaint:___________________________________________________
    _________________________________________________________________
    Characteristics of chief complaint:_______________________________________
    _________________________________________________________________
    Intensity:_________________
    Frequency:_______________
    Location:_________________
    Radiation:________________
    Onset:___________________
    Duration:_________________

3. Other information relevant to the presenting complaint, if any:
    _________________________________________________________________
    _________________________________________________________________

4. Aggravating factors:
    _________________________________________________________________
    _________________________________________________________________

5. Previous interventions, treatments, medications, surgery:     _________________________________________________________________
    _________________________________________________________________

6. Family history:
    Associated health problems of relatives:
    _________________________________________________________________
    _________________________________________________________________
    _________________________________________________________________
    Deaths in immediate family:
    Cause of death                Age at death
    _____________             __________
    _____________             __________
    _____________             __________
    _____________             __________

7. Past health history:
    A. Overall health status:
    _________________________________________________________________
    _________________________________________________________________
    B. Previous illness:
    _________________________________________________________________
    _________________________________________________________________
    C. Surgeries:
            Date            Type of surgery
          ______         ________________________
          ______         ________________________
    D. Previous injury or trauma:
    _________________________________________________________________
    _________________________________________________________________
    E. Medications:
            Medication                            Reason for taking
    _________________                 _______________________
    _________________                 _______________________
    _________________                 _______________________
    _________________                 _______________________
    F. Allergies:
    _________________________________________________________________
    _________________________________________________________________

8. Social and occupational history:
    Level of education:
    [ ]high school
    [ ]some college
    [ ]postgraduate studies

    A. Job description:__________________________________________________
    _________________________________________________________________
    B. Work Schedule:__________________________________________________
    C. Recreational Activities:_____________________________________________
    _________________________________________________________________
    _________________________________________________________________
    D. Lifestyle(hobbies,level of exercise,drug use,diet):
    _________________________________________________________________
    _________________________________________________________________
    _________________________________________________________________
    _________________________________________________________________
    _________________________________________________________________
    _________________________________________________________________

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