Case History

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Case History

Please complete all relevant questions, so that Dr. Bart may be in best service to you. Details appreciated!

Email *

First and last name *

Today's date *

YYYY

Phone number *

Date of Birth *

YYYY

Referred by

Occupation

Address, City, State, ZIP

Approximate Height

Approximate Weight

Have you ever received Chiropractic and/or Acupuncture Care?

Yes

Clear selection

If yes to the above, where?

Purpose of your visit:

Chiropractic

Acupuncture

Nutrition

Select all that apply:

Injury

Pain in low back

Pain in upper back

Joint pain

Headache

Other

Chief complaint *

Secondary complaint

Grade severity of 1 to 10, 1 being no pain, 10 being worst possible pain

Clear selection

What is the QUALITY of the complaint/pain? Select all that apply

Dull

Aching

Sharp

Shooting

Burning

Deep

Nagging

Other

Does this complaint/pain radiate or travel (shoot) to any areas of your body?

Yes

Unsure

Clear selection

If yes to the above, where?

Do you have any numbness/tingling in your body?

Yes

Clear selection

If yes to the above, where?

How frequent is complaint present, how long does it last?

Does anything aggravate the complaint?

Does anything make the complaint better?

Please detail previous treatment medications, surgery or care you've sought for your complaint:

Please detail previous illness/trauma/injury you've had in your life:

Have you ever broken any bones?

Yes

Clear selection

If yes to above, which bones?

Please list current medications/supplements, and reason for taking:

Please list recent vaccinations:

Please detail any surgeries, with date and type of surgery:

Females, please detail pregnancies and outcomes, including date of delivery:

Please detail associated health problems of relatives:

Please detail your recreational activities/exercise:

Please detail your lifestyle (hobbies / alcohol / tobacco / drug use / diet):

What is your daily water consumption, in ounces?

How would you rate your overall diet?

Good

Fair

Poor

Clear selection

I have read the above information and certify it to be true and correct to the best of my knowledge, and hereby authorize this office to provide me with care, in accordance with this state's statutes: (please type name and date in lieu of signature) *

Send me a copy of my responses.

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