History Form
First Name(Nombre) /Last Name (Apellido) *
Your answer
Address/Direccion *
Your answer
Phone Number/No. de Celular *
Your answer
Email Address *
Your answer
Date of birth and age/Fecha de Nacimiento y Edad *
Your answer
Marital Status/ Estatus Marital *
How many children? ¿Cuantos hijos? *
Your answer
Person to notify in case of emergency and phone number/ Contacto de emergencia nombre y numero *
Your answer
Occupation/ Occupacion: *
Your answer
Employer/ Empleador *
Your answer
Name of primary physician/ Nombre de doctor familiar *
Your answer
Have you ever received chiropractic care?/ ¿Ha recibido tratamiento quiropractico? *
Positive Experience? ¿Buena Experiencia? *
Main complaints about your health that you would like to work on? (List all health concerns)/ ¿Que quejas tiene sobre su salud que quiere trabajar en? (Haga lista de quejas) *
Your answer
How much do you smoke per day? ¿Cuanto fuma por dia? *
Your answer
How may drinks per week?¿Cuantas bebidas alcohólicas por semana? *
Your answer
List all medications/supplements herbs you are taking, for how long, and what for./ Haga lista de medicamentos o suplementos que este tomando, por cuanto tiempo y por que razón. *
Your answer
List all surgeries and operations including plastic surgeries. Please date when they occurred./ Haga lista de cualquier sirugía o operación incluyendo cirugías plasticas y cuando ocurrieron. *
Your answer
Allergies: (list food, environmental, chemical and drug.)/ Alergias: (liste comida, medicinas o químicos) *
Your answer
Please rate your stress level on a scale of 1 to 10, 10 being the highest stress and list the cause./ Califique su nivel de estrés en una escala del 1 al 10, siendo 10 el estrés más alto y liste la causa. *
Your answer
How is your sleep? ¿Como duerme? *
Digestion/ Digestión *
How often do you exercise? What kind of exercise?/ ¿Con que frequencia hace ejercicio? ¿Que tipo? *
Your answer
Accidents: Auto/Falls/Sports and when?/ Accidentes: Automóvil/ Caídas/ Deportes ¿y cuando? *
Your answer
Any other health conditions that we should be aware of? (Crohn's, MS)/ ¿Otros problemas que debamos saber? *
Your answer
Is there any IMMEDIATE family history of: / Hay alguna historia INMEDIATA familiar de: *
Please list other immediate family history of diseases if applicable/ Si aplica, favor de listar otras enfermedades de familia inmediata *
Your answer
Women only: Pregnant/ Solo mujeres: Embarazada
Women only: Last menstrual cycle? Are you nursing? / Solo mujeres: ¿Ultimo periodo menstrual? ¿Estas amamantando?
Your answer
Payment Agreement: I understand and agree that health and accidental insurance policies are an arrangement between and insurance carrier and myself. I clearly understand and agree that all services rendered to me and are charged directly to me and that I am personally responsible for payment *
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