Hollenbach Family Chiropractic

Personal Health History
Date: Case No:
Name: Email address:
Address: City/State/Zip:
Date of Birth: Social Security No:
Home Phone No: Work Phone No:
Marital Status: Spouses Name:
Children’s Names and Ages:
Name of Employer: Occupation:
Hobbies:
Who referred you?
Name of previous Chiropractors:
When was your last visit?
How long were you receiving Chiropractic treatment?
Reason for coming in:
What accidents have you had? (i.e. car, sports, slips/falls) at work or at home (include dates):
 
Were you ever knocked unconscious?
What fractures or broken bones have you had? (include dates):
 
Surgery: What major surgery have you had? (include dates):
 
What minor surgery have you had? (tonsillectomy, wart/cyst removal, dental extraction) (include dates):
 
Medication:

Present Prescription Medication

Past Prescription Medication

Over-the-counter Medication
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Your Birth Record
Type of Birth: Vaginal ¨ Cesarean ¨ Other:
Any complications during your mothers’ pregnancy or your birth?
Any complications after your birth?
Current Health
Please use the following to answer questions below: Poor, Good or Excellent
How would you describe your current health?
How would you describe your family’s health?
Describe your: Vision Hearing Coordination
Do you use the following? Tobacco ¨ Alcohol ¨ Coffee/Tea ¨ Cola ¨ Milk ¨
Level of stress in your life: Mild ¨ Moderate ¨ Extreme ¨ 1 2 3 4 5 6 7 8 9 10
Do you purchase any of the following? Bottled water ¨ Vitamins ¨ Health Food ¨
Financial Information
What method of payment will you be using? Insurance ¨ Check ¨ Cash ¨ Credit Card ¨
Who is responsible for this account?
Name of Insurance Company: Policy No: _____________________

Please check any of the following that give you difficulty or you have had recently

1

2

3

4
A___ Headaches A___ Fainting A___ Shortness of Breath A___ Numbness-legs/feet
B___ Shooting head pain B___ Loss of balance B___ Mid-back pain B___ Constipation
C___ Sinus Trouble C___ Ringing in ears C___ Heart Attack C___ Kidney trouble
D___ Loss of smell D___ Blurred vision D___ Low blood pressure D___ Menstrual cramps/pain
E___ Allergies E___ Lights bother your eyes E___ High blood pressure E___ Menstrual irregularity
F___ Hayfever F___ Neck pain F___ Anemia F___ Diabetes
G___ Asthma G___ Neck muscle spasm G___ Stomach trouble G___ Sleeping problems
H___ Loss of taste H___ Grinding in neck H___ Nervousness H___ Painful joints
I___ Inflammation of throat I___ Shoulder/arm tightness I___ Inner tension I___ Swollen joints
J___ Thyroid trouble J___ Shoulder/arm pain J___ Irritability J___ Pins & needles in legs
K___ Twitching of face K___ Pins & needles in arms K___ Gall bladder trouble K___ Swollen ankles
L___ Loss of memory L___ Pins & needles in hands L___ Indigestion L___ Cold feet
M___ Fatigue M___ Cold hands M___ Intestinal gas M___ Pain in legs/feet
N___ Depression N___ Numbness – arms/hands N___ Low back pain N___ Hip pain
O___ Dizziness O___ Swollen tonsils O___ Hernia O___ Facial pain
P___ Spinal curvature P___ Prostate trouble P___ Stroke P___ Jaw pain (TMJ)
Q___ Chest pain

Q___ Bed wetting

Q___ Arthritis

Q___ Ulcers
R___ Earache

R___ Cancer

R___ Facial twitch
Office use: _________________________ _________________________ _________________________
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