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  • INTRODUCTION PATIENT CASE HISTORY

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  • Patient Information

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  • Emergency Contact Information

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  • Financial Information



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  • HISTORY OF PRESENT ILLNESS

  • History of Present Illness

    Please describe.
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  • Major Complaint






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  • PAST, FAMILY, AND SOCIAL HISTORY

  • Past Medical History

    Have you ever had any of the following? Please select all that apply and use comments to elaborate.



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  • Family History

    Please check off all that apply and use comments to elaborate.
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  • Social and Occupational History



  • REVIEW OF SYSTEMS

    Many of the following conditions respond to chiropractic treatment.

  • Are you currently experiencing any of these symptoms?

    Please select all that apply and use comments to elaborate.















  • I have answered these questions to the best of my knowledge and certify them to be true and correct.

  • Clear

  • FUNCTIONAL RATING INDEX

    For use with Neck and/or Back Problems only

  • In order to properly assess your condition, we must understand how much your neck and or back problems have affected your ability to manage everyday activities.

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  • Should be Empty: