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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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