Confidential Patient Information

If you need any assistance completing this form, please ask the receptionist.

Patient ID:

Identifying Information

Today's date:

Date of Birth:

Age:

Name:

Sex:

Male Female

Address:

City:

State:

Zip:

Home Phone:

Work Phone:

May We Contact You Using Any of the Above Methods?

Yes No

Preferred Method:

If other:

Name of Spouse/Partner or Nearest Relative:

Phone:

Number of Children:

Ages of Children:

State your HEIGHT:

State your WEIGHT:

Please Indicate How You Were Referred to Our Office

Patient of Dr. Garcia (Name):

Family Member (Name):

Attorney (Name):

Friend (Name):

Staff Member (Name):

Screening (Where):

Other Doctor’s Office (Name):

Employment and Payment Options

Payment for Services:

Cash Check Credit Card CHUSA Auto Insurance Other

Name of Insurance Company:

Insured’s SSN or ID#:

Insured’s Employer:

Employer’s Phone #:

Secondary Insurance Coverage:

Yes No

Name

Occupation:

Employer:

Females ONLY

Are You Pregnant?

Yes No

Date of Last Menstrual Cycle:

Using Birth Control?

Yes No

If Yes, How Long?

Method of Birth Control:

Signature:

Date:

Dr. Initials

Patient History

What are you chief complaints for this visit?

Add complaints

Weight Frequently Required to Lift is Under:

10 lbs. 20 lbs. 30lbs. 40 lbs.

Lifting/Bending is Less Than:

30 min 1 hr. 2 Hrs. 3 Hrs. 4 Hrs.

Date of last physical exam:

Date of last lab (Blood, Urine, Stool):

Have you ever experienced a stroke?

Yes No

If Yes, Date of Stroke:

Have you ever experienced blood clots?

Yes No

If Yes, Date:

and Location:

Are you taking any blood thinning medication?

Yes No

If Yes, Name of Medication:

Have you ever had a metal implant?

Yes No

If Yes, Date:

and Location:

Have you ever been gunshot?

Yes No

If Yes, Date:

and Location:

Social History:

Alcohol Use Non-Alcohol USe Smoker Non-Smoker

Have you ever tried to “crack,” “adjust,” “manipulate,” or “pop” your neck, back, etc.?

Yes No

If Yes (Please describe)

Have you ever tried to have a non-professional “crack,” “adjust,” “manipulate,” or “pop” your neck, back, etc.?

Yes No

If Yes (Please describe)

Is today’s problem caused by:

Auto Accident Workman's compensation

Have you had previous chiropractic care?

Yes No

If yes, when?

Indicate on the drawings below where you have pain/symptoms

Signature:

Date:

Dr. Initials

Patient History

What is your:

Height:

Weight:

What is your:

Occupation:

How would you rate your overall health?

Excellent Very Good Good Fair Poor

What type of exercise do you do?

Strenuous Moderate Light Non

Indicate if you have any immediate family members with any of the following:

Rheumatoid Arthritis

Diabetes

Lupus

Heart Problems

Cancer

ALS

For each of the conditions listed below, check the box for “past” if you have had the condition in the past. If you presently have a condition listed below, check the box in the “present” column.

(Please Describe):

FEMALES ONLY

List all prescription medications and/or over-the-counter medications (ex: aspirin, Tylenol, Advil, etc.) you are currently taking.

Add Prescription

List all of the supplements/vitamins you are currently taking.

Add Supplements/Vitamins

List all of the surgical procedures you have had.

Add Surgical Procedure

What activities do you do outside of work?

Signature:

Date:

Dr. Initials

History of Current Complaint(s)

Complaint – Please List ONLY ONE complaint per sheet.

Add Another Complaint

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