1141 N Brand Blvd Suite 200 Glendale, CA 91202

Home
New Patient Center
About Us
- Meet The Staff
- Services & Techniques
Read Our Reviews
Community Content

1141 N Brand Blvd Suite 200 Glendale, CA 91202

Schedule an Appointment | 818-484-8944

Home
New Patient Center
About Us
- Meet The Staff
- Services & Techniques
Read Our Reviews
Community Content

Home

New Patient Health History Form

New Patient Health History Form

In order to provide you the best possible wellness care, please complete this form

Patient Data

First Name*

Last Name*

Date

Email (Your email will NOT be shared with any third parties, and is used for occasional office announcements and promotions.) *

Mailing Address

Address

City

State

Zip

Telephone (Home)

Telephone (Work)

Referred By

Age

Birth Date

Social Security #

Number of Children

Occupation

Employer

Marital Status

Spouse's Name

Spouse's Occupation

Spouse's Employer

Spouse's Health Status

Emergency Contact

Phone

Current Complaints

Nature of Injury

Automobile Work Other

Please Describe

Date of Injury

Date Symptoms Appeared

Have you ever had same condition?

No Yes

If yes, when

List other practioners seen for this injury/condition

Have you ever been under chiropractic care?

No Yes

If yes, please describe

Insurance Information

Name of party responsible for payment

Phone

Do you have health insurance?

No Yes

Name of company

Insurance company name

Contact person

Phone

Claim #

Signatures

Name of the Insured ____________________________________

I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.

Patient's signature ____________________________________

Date ________________________________

Spouse's or guardian's signature ____________________________________

Date ________________________________

Medical History

Have you been treated for any conditions in the last year?

No Yes

If yes, please describe

Date of last physical exam

Is there a chance that you are pregnant?

No Yes

Have you had X-rays taken?

No Yes

If Yes, where?

What medications are you taking and for what conditions (Please list dosage and amounts, etc).

What vitamins, minerals, or herbs do you currently take? (Please list for what condition, dosage, and frequency).

Have you ever:

Broken bones?

No Yes

Briefly explain

Been hospitalized?

No Yes

Briefly explain

Been in auto accident?

No Yes

Briefly explain

Had Sprains/Strains?

No Yes

Briefly explain

Been struck unconscious?

No Yes

Briefly explain

Had surgery?

No Yes

Briefly explain

Family History

Family members - Present and past health conditions (Example: heart disease, cancer, diabetes, arthritis, etc.)

Do you experience pain every day?

No Yes

Do your symptoms interfere with daily life?

No Yes

Does pain wake you up at night?

No Yes

Are your symptoms worse during certain times of the day?

No Yes

Do changes in weather affect your symptoms?

No Yes

Do you wear orthotics?

No Yes

Do you take vitamin supplements?

No Yes

What activities aggravate your symptoms?

Habits

Alcohol

No Yes

Coffee

None Light Moderate Heavy

Tobacco

None Light Moderate Heavy

Drugs

None Light Moderate Heavy

Exercise

None Light Moderate Heavy

Sleep

None Light Moderate Heavy

Appetite

None Light Moderate Heavy

Soft Drinks

None Light Moderate Heavy

Water

None Light Moderate Heavy

Salty Foods

None Light Moderate Heavy

Sugary Foods

None Light Moderate Heavy

Artificial Sweeteners

None Light Moderate Heavy

Have you ever suffered from:

Alcoholism Allergies Anemia Arteriosclerosis Arthritis Asthma Back Pain Breast Lump Bronchitis Bruise Easily Cancer Chest Pain Cold Extremities Constipation Cramps Depression Diabetes Digestion Problems Dizziness Ears Ring Excessive Menstruation Eye Pain or Difficulties Fatigue Frequent Urination Headache Hemorrhoids High Blood Pressure Hot Flashes Irregular Heart Beat Irregular Cycle Kidney Infection Kidney Stones Loss of memory Loss of balance Loss of smell Loss of taste Lumps In Breast Neck Pain or Stiffness Nervousness Nosebleeds Pacemaker Polio Poor Posture Prostate Trouble Sciatica Sexually Transmitted Infection Shortness of breath Sinus Infection Sleep problems or Insomnia Spinal Curvatures Stroke Swelling of ankles Swollen Joints Thyroid Condition Tuberculosis Ulcers Varicose Veins Other

Other

Please do not submit any Protected Health Information (PHI).

Thank you. Your submission has been sent.

Error!

Office Hours

Monday

9 AM - 12 PM

2 PM - 6 PM

Tuesday

9 AM - 12 PM

2 PM - 6 PM

Wednesday

9 AM - 12 PM

2 PM - 6 PM

Thursday

9 AM - 12 PM

2 PM - 6 PM

Friday

9 AM - 1 PM

Closed

Saturday

By appointment only.

Sunday

By appointment only.

Genesis Chiropractic & Wellness Center

Find us on the map

--mi

Genesis Chiropractic & Wellness Center

Address

1141 N Brand Blvd Suite 200
Glendale, CA 91202, US

Contact Information 818-484-8944

818-484-8943

[email protected]

-- mi Genesis Chiropractic & Wellness Center
-- mi Genesis Chiropractic and Wellness Center Satellite

CONTACT US

Name*

Email *

Phone *

Comments

Please do not submit any Protected Health Information (PHI).

Thank you. Your submission has been sent.

Error!

1141 N Brand Blvd Suite 200 Glendale, CA 91202
818-484-8944

Admin Log In
Site Map