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Your body is designed to be healthy. Unfortunately, life happens and various events damage your health. This case history will help us at Palmetto Chiropractic understand how we can get you back to your healthy state. Please remember, just as it was a process to becoming unhealthy, it will be a process to becoming healthy again.
When did you last see a Chiropractor?
Reason for last visit
Specific Health Issue
Have you ever been taught how to maintain a healthy spine and nervous system?
If yes, what were you taught?
Have you ever been placed on a health maintenance plan?
List activities you do that you feel promote health
Reason for visit
How did injury begin?
Have you had this problem before?
If yes, when and what treatment did you seek?
Is the problem
staying the same
come and go
Is it the worst in the
Is it interferring with
quality of life
Is it interferring with any of the following hobbies?
What helps the problem?
What worsens the problem?
medication side effects
What are your expectations of us in reference to this problem?
How committed are you to restoring your overall health as well as your
present problem? ( 1-10, 10 being the healthiest possible )
Other indicators of ill health
dizziness/loss of balance
pins & needles in legs/arms
numbness in fingers/toes
shortness of breath/chest pains
lights bother eyes
Accidents & Trauma
slip/fall from bed/couch/down stairs
falling when learning to walk
If so, how
any other trauma/accidents
Life presents chemical, physical, & mental stresses that have a major influence on our health. Please check all that apply to your current lifestyle.
did/do you smoke?
amt per day
did/do you drink alcohol
how many times per week
rate your diet ( 1-10, 10 being the healthiest possible )
mental stress (deadlines, family, health)
drugs (prescription/over counter)
When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both the patient and doctor to be working towards the same objective. Chiropractic has only one goal. It is important that each patient understand both the objective and the method that will be used to attain it. This will prevent any confusion or disappointment.
Adjustment: An adjustment is the specific application of forces to facilitate the body's correction of vertebral subluxation. Our chiropractic method of correction is by specific adjustments of the spine.
Health: A state of optimal physical, mental and social well-being not merely the absence of infirmity.
Vertebral Subluxation: A misalignment of one or more of the 24 vertebra in the spinal column, which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body's innate ability to express its maximum health potential.
We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if during the course of a chiropractic spinal examination, we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of a health care provider who specializes in that area.
Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. OUR ONLY PRACTICE OBJECTIVE is to eliminate a major interference to the expression of the body's innate wisdom. Our only method is specific adjusting to correct vertebral subluxations.
I, have read and fully understand the above statements. All questions regarding the doctor's objectives pertaining to my care in this office have been answered to my complete satisfaction.
All questions regarding the doctor's objectives pertaining to my care in this office have been answered to my complete satisfaction.
I therefore accept chiropractic care on this basis.