CaseHistoryForm

You may fill out your history and intake information
online if you wish... All fields with a RED " * " must be
filled in!

Please provide the following contact information:
Date	*
First name	*
Last name	*
Middle initial
Date of Birth	* mm/dd/yyyy
Title
Street address	*
Address (cont.)
City	*
State/Province	*
Zip/Postal code
Country
Soc. Sec. No.
Work Name
Work Phone
Home Phone
FAX
E-mail	*

Present Complaints
Please list your complaints below. Start with the most significant complaint as the "Chief Complaint" then below there will be an opportunity for a secondary complaint and a third complaint, etc.
Chief Complaint
Chief Complaint
Occured how?
Onset (time/date)
What makes it feel better?	rest, heat, cold, hot bath, lying down, Other
Type of pain	Sharp Dull Throbbing Boring Numb Tingling Shooting Ache Other
Does the pain radiate into...	Right Arm Left Arm Right Leg Left Leg Right Side Left Side Other
What setting makes it worse?	Work Home Exercise AM PM, Other
What activity makes it worse?	Bending Stooping Lifting Walking Running Sex Sitting Lying Down, Other
Severity	Mild Mild to Moderate Moderate Moderate to Severe Severe Very Servere
Timing	Constant Constant with intensity varying.
Progression	Getting: Better Worse Staying Same
Comments	Include any comments you have about the chief complaint in this box.
Secondary Complaint
Second complaint
Occured how?
Onset (time/date)
What makes it feel better?	rest, heat, cold, hot bath, lying down, Other
Type of pain	Sharp Dull Throbbing Boring Numb Tingling Shooting Ache Other
Does the pain radiate into...	Right Arm Left Arm Right Leg Left Leg Right Side Left Side Other
What setting makes it worse?	Work Home Exercise AM PM
What activities makes it worse?	Bending Stooping Lifting Walking Running Sex Sitting Lying, Other
Severity	Mild Moderate Severe Very Severe
Timing	Constant Constant with varying intensity
Progression	Getting: Better Staying Same Worse
Comments	Include any comments you have about this complaint in this box.
Third Complaint
Third complaint
Occured how?
Onset (time/date)
What makes it feel better?	rest, heat, cold, hot bath, lying down, Other
Type of pain	Sharp Dull Throbbing Boring Numb Tingling Shooting Ache Other
Does the pain radiate into...	Right Arm Left Arm Right Leg Left Leg Right Side Left Side Other
What setting makes it worse?	Work Home Exercise AM PM, Other
What activities makes it worse?	Bending Stooping Lifting Walking Running Sex Sitting Lying, Other
Severity	Mild Moderate Severe Very Severe
Timing	Constant Constant with varying intensity
Progression	Getting: Better Worse Staying Same
Comments	Place any additional comments about this complaint in this box.

CaseHistoryForm

Mefford Chiropractic Center, Ltd. Last revised: March 27, 2006 07:23 PM

Mefford Chiropractic Center, Ltd.
Last revised: March 27, 2006 07:23 PM