BK2HLTH Case History

Desired Appointment Time

(Please keep in mind that a representative from our office will contact you within 24 hours of submission to confirm availability of requested date and time. First time patients please complete the "New Patient Form" below)

Monday and Wednesday: 9 am - 12 pm and 2 pm - 6 pm

Tuesday and Thursday: 2:00 pm – 6:00 pm

Friday: 9:00 am – 1:00 pm

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MonthDayYear

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Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Race

Ethnicity

Language

E-mail*

Birth Date*

MonthDayYear

Home Phone Number*

Area CodePhone Number

Cell Phone Number*

Area CodePhone Number

Employer

Occupation

Marital Status

Spouses Name

Number of Children & Ages

Referred by

Emergency Contact

Emergency Contact #

Have You Ever Received Chiropractic Care?*

The human body is designed to be healthy. Throughout life, events occur which damage your health expression. This case history will uncover the layers or damage, especially to your nervous system, that have resulted in poor health. Following your exam, your chiropractor will ourline a course of care to begin to correct these layers of damage and recover your innnate health potential.

Let's begin with at birth when you first damaged your nerve system, lost your wellness and begin your hourney to ill health.

1. Pregnancy

Did your mother:

	Yes	No
Smoke or drink alcohol?
Have a proper diet?
Exercise through her pregnancy?
Experience any falls and injuries during pregnancy?
Experience any physical and/or mental abuse?

2. Birth Process

	Yes	No
Was the delivery long?
Was the delivery difficult?
Forceps
Cesarean?
Home birth?
Breach/Cephalic?
Home birth?
Hospital birth?
Mother given drugs during delivery?
Was labor induced?

2. Birth Process

	Yes	No
Were you taught how to take care o your spine?
Did you roll our of bed?
Were you a headbanger or rocker?
Were you breast fed?
Childhood sicknesses?
Accidents?
Surgery?
Drugs?
Did you fail while learning to walk?
Were you picked on by siblings?
Child abuse?
Spanking?
Pulled Ear/Chin?
Other?
Chair Pulled our when sat down?
Did you fall down stairs?
Where you yanked by your arm?
Did you have other trauma?

	Yes	No
Were you taught proper body movements and care?
Did you/do you smoke?
Did you/do you drink alcohol?
Did you/do you drink caffeine
Weight gain or loss?
Have you been in accidents?
Have you had surgery and organs removed/replaced?
Drugs? (Prescriptive or Non-prescriptive)
Drug Allergies?
Environmental Allergies?
Teeth problems?
Eye problems?
Hearing problems?
Exercise regularly?
Loss of sleep?
Did/do you have occupational stress?
Physical stress?
Mental stress?
Hobbies/Sports injuries?
Other traumas or problems?

Please feel free to elaborate on any yes answers.

Finally, the years of continuing damage showed up as acute or chronic symptoms.

Draw in the Pain

Present Complaint (Be Brief)

Major

Pain or Problem Started On

What Activities aggravate your condition/Pain?

Pains are:

On a Scale of 1 to 10 is Your Pain Level

What Activities lessen your condition/Pain?

Is condition worse during certain times of the day?

Is this condition interfering with:

Work?Sleep?Routine?Other?

Is Condition getting progressively worse?

YesNo

Other Doctors seen for this condition

Any home remedies?

Other Symptoms: O=Occasional F=Frequent C=Constant NA=Not Applicable

	O	F	C	NA
Headaches
Neck Pain
Sleeping Problems
Back Pain
Nervousness
Tension
Chest Pain
Dizziness
Face Flushed
Neck Stiff

	O	F	C	NA
Pins & Needles in Legs
Pins & Needles in Arms
Numbness in Fingers
Numbness in Toes
Shortness of Breath
Fatigue
Depression
Lights Bother Eyes
Loss of Memory
Ears Ring

	O	F	C	NA
Fainting
Loss of Smell
Loss of Taste
Diarrhea
Feet Cold
Hands Cold
Stomach Upset
Cold Sweats
Loss of Balance

	O	F	C	NA
Acid Re-flux
Fever
Buzzing in Ears
Arm Pain
Bladder Control
Bowel Control
Elbow Pain
Sciatica
Skin Problems

List Vitamins and Herbal Support?

Have you ever been under drug and medical care?

What medications are you taking?

How Long?

Have you had surgery?

What?

When

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	Heart Disease	Arthritis	Cancer	Diabetes	Other
Father Side
Mother Side

Chiropractic provides three types of care. The first is 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.

Signature Patient or Gaurdian*

Signature for Consent to Treat a Minor

Signature of Person Responsible for Payment*

Submission Date

MonthDayYear

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About Your Health

Loss of Wellness (Birth-Age 5)

Loss of Whole Body Health (Age 5 to Present)

Symptoms and ill health (Present state of ill health)

About Your Care