CASE HISTORY
Name ____________________________________ Today’s Date _________________
_______________________________________________________________________
Have you seen another doctor for this condition? No Yes if yes explain ____________
_______________________________________________________________________
Are you currently taking any medication, prescription or over-the-counter? No Yes if yes explain______________________________________________________________
Are you currently under the care of another physician for any condition(s)? No Yes if yes explain______________________________________________________________
Have you ever been diagnosed with any of the following conditions?
AIDS/HIV Cataracts Hepatitis Osteoporosis Suicide Attempt
Alcoholism Chemical Dependency Hernia Pacemaker Thyroid Problems
Allergies Chicken Pox Herniated Disc Parkinson’s Tonsillitis
Anemia Depression Herpes Pinched Nerve Tuberculosis
Anorexia Diabetes High Cholesterol Pneumonia Tumors/Growths
Appendicitis Emphysema Kidney Disease Polio Typhoid Fever
Arthritis Epilepsy Liver Disease Prostate Problems Ulcers
Asthma Fractures Measles Prosthesis Vaginal Infections
Bleeding Disorders Glaucoma Migraines Psychiatric Care Venereal Disease
Breast Lump Goiter Miscarriage Rheumatoid Arth. Whooping Cough
Bronchitis Gonorrhea Mononucleosis Rheumatic Fever Other ___________
Bulimia Gout Multiple Sclerosis Scarlet Fever ________________
Cancer Heart Disease Mumps Stroke ________________
Date(s) of last exam(s) _____________________________________________________
List all surgeries with dates _________________________________________________
________________________________________________________________________
What type of exercise do you perform and how often: ____________________________
________________________________________________________________________
What are your daily work habits (ex: sitting, lifting, heavy lifting, typing, computer input)
________________________________________________________________________________________________________________________________________________
Do you smoke? No Yes if Yes how much _________________
Do you drink alcohol? No Yes if Yes what and how much per week _______________
Do you drink caffeinated beverages No Yes if yes what and how much/wk __________