penn chiropractic clinic
Case History

Please submit this on-line case history for pre-registration into the Penn Chiropractic Clinic.
We will contact you when we successfully receive your completed form. Please view and print the Terms of Acceptance prior to visiting the office.

Name
Address
City
State
Zip Code
Work Phone
Home Phone
FAX
E-mail
Today's Date: -- mm/dd/yy Date of Birth: -- mm/dd/yy
Referred By:
Social Security Number: Spouse's Occupation
Occupation:
Employer:

Marital Status:

 Spouse:

List your children's names/ages:

Have you ever had chiropractic care?
About Your Health
The human body is designed to be healthy. Throughout life, events occur which damage your health expression. This case history will uncover the layers of damage, especially to your nerve system, that resulted in poor health. Following your exam, your Chiropractor will outline a course of care to begin to correct these layers of damage and recover your innate health potential.
Loss of Wellness
Let's begin at birth when you first damaged your nerve system, lost your wellness and began your journey to ill health.
Birth Process
Was the delivery long? Yes No Was the delivery difficult? Yes No
Forceps? Yes No Caesarean? Yes No
Breach/cephalic? Yes No Home birth? Yes No
Hospital birth? Yes No Was labor induced? Yes No

Mother given drugs during delivery?

 Yes No
Growth and Development
Were you taught how to care for your spine? Yes No
Did you fall out of bed? Yes No
Were you a headbanger or rocker? Yes No
Were you breast fed? Yes No
Any childhood sicknesses? Yes No
Accidents? Yes No Surgery? Yes No
Drugs? Yes No Child abuse? Yes No
Did you fall while learning to walk? Yes No
Were you picked on by siblings? Yes No
Spanking? Yes No Pulled ear/chin? Yes No
Chair pulled out when sat down? Yes No
Did you fall down the stairs? Yes No
Were you yanked by your arm? Yes No
Did you have other traumas? Yes No
Current Health Habits
Did/do you smoke?  Yes No Did/do you drink any alcohol? Yes No
Do you eat healthy foods? Yes No Have you been in accidents? Yes No
Have you had surgery and organs removed/replaced? Yes No
Drugs? (Prescriptive or non-prescriptive) Yes No
Teeth problems? Yes No Eye problems? Yes No
Hearing problems? Yes No Exercise regularly? Yes No
Sleeping (nightmares?) Yes  No Occupational stress? Yes No
Physical stress? Yes No Mental stress? Yes No
Hobbies/Sports injuries? Yes No Sleeping posture side stomach back
 
PRESENT COMPLAINT - MAJOR PAIN ISSUE
Date Problem Started On:
-- mm/dd/yy
Pains are:     
Activities that AGGRAVATE your pain:
Activities that LESSEN your pain:

When is the condition at its worst?

Morning
 Late Morning
 Afternoon
 Late Afternoon
 Night

This condition interferes with:

Work
 Sleep
 Routine

 
Is condition getting progressively worse? Yes No
Other doctors seen for this condition:
Any home remedies used:

Other symptoms (check all that apply):

Headaches               Neck Pain             Sleeping Problems    Back Pain             
Nervousness             Tension                 Irritability                             
Dizziness                 Face Flushed         Neck Stiff               
Pins & Needles in Arms  Pins & Needles in Legs     Chest Pains 
Numbness in Fingers      Numbness in Toes            Shortness of Breath   
Fatigue                     Depression           Lights Bother Eyes      Loss of Memory        
Ears Ring                 Fever                    Fainting                      Loss of Smell         
Loss of Taste            Diarrhea                Feet Cold                   Hands Cold            
Stomach Upset         Constipation          Cold Sweats               Loss of Balance       
Buzzing in Ears
Have you been under drug and medical care? Yes No
What medications are you taking?
For how many months?   
What side effects have you experienced from medications and surgery?
Is there a family history of:

Heart Disease (father)
 Heart Disease (mother)
 Arthritis (father)
 Arthritis (mother)
 Cancer (father)
 Cancer (mother)
 Diabetes (father)
 Diabetes (mother)
About Your Care
Chiropractic provides three types of care. The first us Initial Intensive Care which corrects the most recent layer of Spinal and Neurological damage (VSC). This care usually reduces or eliminates the symptoms. Then begins Reconstructive Care which corrects the years of damage that occurred when there were few symptoms. And finally, Chiropractic offers a genuine approach to Wellness Care. All of these options will be explained at your report of findings. Then you'll be able to begin a course of care that fits your health goals.

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Copyright © 2003 Penn Chiropractic Clinic. All rights reserved.
Revised: 03/04/03