ASAP SPINAL HEALTH CONFIDENTIAL CASE HISTORY FORM

ASAP SPINAL HEALTH CONFIDENTIAL CASE HISTORY
Please fill out as thoroughly as possible.
Background Information
Name	SSN	Date of Birth		Age
Address	City	St	Zip
Hm Phone	Wk Phone	Cell Phone		Drivers Lic
Sex	Marital Status	Num. of Children		Num. at Home
Occupation	Employer	Years Employed
Name of Spouse	Work Num.	Occupation
Name of Doctor	Doctor City	Doctor Phone
Name of Specialist	Specialist City	Specialist Phone

Medical History
Please check any conditions that you have had or have currently.
Chronic Infection	Diabetes	Arthritis	Meningitis	Cancer
Fractures	Tuberculosis	Heart Disease	Kidney Disease	Hepatitis
Asthma	Aids	Osteoporosis	Lung Disease	Stress
Ulcers	Depression	Skin disease	Gall Stones	Rheumatoid Arth.
Other
Allergy to Medication? (List)
Are you pregnant?
List Current Medications
Prior Surgeries/Accidents

Current Problem

(If more than one, describe the worst)

Date of Injury or Onset

Please describe your current problem?

Have you seen a Physician/Hospital for this condition?

What treatment have you had for this condition?

Have you had X-Ray's, MRI's or lab work for problem?

How bad is your pain? ( 0 - No Pain 10 - Unbearable Pain )

Please check all areas of you complaint
Shoulder	Upper Back	Head
Upper Arm	Lower Back	Eyes
Lower Arm	Buttocks	Nose
Hand	Knee	Ear
Thigh	Chest	Jaw
Calve	Abdomen	Mouth
Foot	Groin	Neck


	Email (if applicable)