Full Name

Marital Status

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

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

Date Began

How did injury begin?

Have you had this problem before?

If yes, when and what treatment did you seek?

What helps the problem?

What worsens the problem?

What are your expectations of us in reference to this problem?

Other indicators of ill health

Accidents & Trauma

Life presents chemical, physical, & mental stresses that have a major influence on our health. Please check all that apply to your current lifestyle.

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.