Patient Intake Form
Thank you for choosing Lake Gregory Chiropractic for your health care needs. Please fill this form out as thoroughly as possible. In most cases it takes no longer than about 10 minutes. You must submit this form before your appointment so we can review your information responsibly. Please call us at 909-338-6477 if you have any questions.
Last Name *
Your answer
First Name *
Your answer
Middle Initial
Your answer
Name Suffix
Date of Birth *
MM
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DD
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YYYY
Age
Your answer
Sex *
Required
Social Security Number
Your answer
Weight *
Your answer
Height *
Your answer
Marital Status
Employment Status
Occupation/Professional Title
Your answer
Preferred Language
Your answer
Smoking
Frequency
End Date
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DD
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YYYY
Race
Street Address
Your answer
PO Box
Your answer
City, State, Zip
Home Phone *
Your answer
Work Phone
Your answer
Cell Phone
Your answer
Preferred Phone
Fax
Your answer
Email
Your answer
Would You Like Appointment Reminders?
Employer Name
Your answer
How Would You Like These Reminders?
Employer Phone
Your answer
Employer City/State
Your answer
Emergency Contact Name
Your answer
Relationship to Patient
Your answer
Emergency Contact Home Phone
Your answer
Emergency Contact Work Phone
Your answer
Emergency Contact Cell Phone
Your answer
What Type of Case
Have you had any of the following *
Required
Family History of Cancer
Family History of Diabetes
Family History of High Blood Pressure
Family History of Cardiovascular Disease/Stroke
Please list all current health conditions or illnesses
Your answer
Please list all surgeries and the year performed
Your answer
Please list all prescription medications
Your answer
Please list all supplements that you take
Your answer
Life Threatening Allergies
Your answer
What is the reason you are seeking our help? (you may choose more than one)
Have you seen any other Doctors for this?
Of so, who?
Your answer
Have you had an X-ray, CTscan or MRI of your spine in the last 5 years?
If so, where?
Your answer
Have you missed any days of work for this condition?
If so, how many?
Your answer
What are your goals regarding your care at our office? (you may answer more than one)
Who referred you to our office?
Your answer
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