Frank Gilson, D.C.

Office (415) 431-7600 Fax (415) 431-7608

290 Division St. Suite 400 San Francisco, CA 94103

Potrero Chiropractors

A Wellness Center

CONFIDENTIAL CASE HISTORY

Patients Name: What Caused Your Pain, Problem, or Symptoms? (Explain) Dont Know Auto Accident Todays Date: Work Injury Other

It Began:

Suddenly

Slowly

Comes and Goes Yes No

It Has Lasted:

Hours

Days

Weeks

Months

Years

Have You Ever Had This Problem Before? If Yes, When? List Doctors Seen For This Problem: 1. Any Treatment Given? 2. Any Treatment Given? 3. Any Treatment Given? Yes No, What Yes No, What Yes No, What

How Long? None Type of Doctor

How Many Times?

Type of Doctor

Type of Doctor

Any Other Treatment, Self Treatment or Medications For This Problem? If Yes What Type Have You Had Any Changes In: Bowel Bladder or Sexual Function

Yes

No

No

Yes, Explain

What Makes Your Condition Worse? Nothing Standing Sitting Movement Exercise Trying to Stand Other

What Makes Your Condition Better? Nothing Exercise Rest Cold Hot No Loss of Sleep Confusion Headache ( Convulsions Daily Weekly) Bad Moods Medication Other

Do You Have Any Nervous System Complaints? Blurred Vision Depression Numbness Forgetfulness

Dizziness Fainting Other (Please List):

Buzzing or Ringing in Ears

Frank Gilson, D.C. Office (415) 431-7600 Fax (415) 431-7608

290 Division St. Suite 400 San Francisco, CA 94103

Potrero Chiropractors

A Wellness Center

CONFIDENTIAL CASE HISTORY PAGE 2

Have You Ever Had Any Of The Following? Cancer Scarlet Backaches Dizziness Other If Yes Please Describe: (When, Treatment, Any Current Problems Resulting? Scarlet Sinus Trouble Heart Trouble Arthritis No Asthma Tuberculosis Epilepsy Diabetes Polio Convulsions Numbness Hepatitis Digestive Problems Muscular Dystrophy High Blood Pressure Multiple Sclerosis Rheumatic Fever Nervousness Concussion German Measles

Any Surgeries? Describe and When:

Yes

No

Any Broken Bones? Describe and When:

Yes

No

Are You Taking Any Other Medications? Describe and When:

Yes

No

Are You Currently Employed? Are You Currently Working? Can You Continue To Work?

Yes Yes

No No

Occupation Yes (No heavy work) Yes (Light duty only) No

Yes (Full duty) No

Is Your Condition Interfering With Your? Work Sleep House Work No

Child Care

Recreation

Other

Ladies, Are You Pregnant?

Yes, When is the baby due? Was Everything OK? Yes No

When Was Your Last Medical Examination? If No, please explain Any Additional Comments You Feel Are Important:

Signature of Patient or Guardian