COMEAU HEALTH CARE ASSOCIATES, PC
Wayne A. Comeau, DC, DACBOH
Parry N. Comeau, P.T., D.C.
194 NORTH STREET
DANVERS, MA 01923-1242
Patient Case History
_________________________________
A thorough case history is an important part of evaluating your
condition and arriving at a diagnosis. Please fill out this form
in as much detail as possible. The doctor will review the history
with you and answer any questions you might have.
__________________________________
Personal Data
Today's Date:________________ Home Phone: ______________
First Name:______________________ Middle Initial:________
Last Name:____________________________________________
Nickname:______________________________ Marital Status: M S D W
Date of Birth:_______________________ Age:_________ S.S. #____-___-___
Address:________________________ City:____________ State:_____ Zip:__________
Occupation:_________________________ Employer:_________________
Work Phone:______________ Number of hours a week you work? ___________
Are you currently able to work? ____Yes ____No If no, list dates out of work:________
Date of Your Last Physical Examination:____________________
In case of emergency please contact_______________________ Phone:______________
Are you: __right handed __left handed __ambidextrous
Patient's Signature:______________________________
(Guardian If Minor)
Current Complaints
The pain/problem began on or about:____________
How long have you been having the pain? __ 1 week or less __ 1 to 6 weeks
__ greater than 6 weeks but
less than 3 months
__ 3 months to 1 year __ over 1 year
Please list your areas of pain in order of severity. .
1. Area of Pain:______________________________________________________
2. Area of Pain:______________________________________________________
3. Area of Pain:______________________________________________________
4. Other:____________________________________________________________
In general my symptoms are better in: __ AM __ Midday __ PM.
In general my symptoms are worse in: __ AM __ Midday __ PM.
__ symptoms do not change with the time of day.
Do you have night pain unrelated to movement? __Yes __No
Do you have constant pain unrelated to movement? __Yes __No
Are your symptoms / condition: __ improving __ unchanged __ getting worse.
List medications you are currently taking, prescribed or over the counter:
1. ______________________________ for ______________________________
2. ______________________________ for ______________________________
3. ______________________________ for ______________________________
4. ______________________________ for ______________________________
5. ______________________________ for ______________________________
Have you seen specialist(s) for this condition? __ Yes __ No
If Yes, Name:__________________________ Location / Town:________________
If Yes, Name:__________________________ Location / Town:_________________