ENGLISH FORM por Centro Quiropractico Cartagena | Jul 1, 2020 Please fill in this form to facilitate the managing of your file and to enable us to give you a better service. The objective of this form is to get to know you better and to be able to give you a more personalized service. Personal Data Name and Surname: Age: Date of Birth: Address: City: Province: Postal Code: Home Phone: Work Phone: Mobile Phone: Profession: Email: Do you have children?: Children Ages: Marital Status Single Married Divorced Widow/Widower Ninguna Who can we thank for recommending our center to you? What is the reason for your visit? Have you ever been in a Chiropractic Centre before? Do you exercise regularly? If so, What kind of sport? Physical Stress: Have you ever have had an accident? If so, When? Have you ever have had surgery? If so, When and Why? During the day, you tend to be: Seated Standing Up Driving Stressed In front of a computer Physical Work Repeating the same movement Ninguna Chemical Stress How much fruits and vegetables do you include in your diet? Mark your intake level: None Little Moderate High Ninguna How many dairy products (milk, yogurt, cheese..) do you include in your diet? Mark your intake level: None Little Moderate High Ninguna How much bread, bakery, cereals or pastries do you include in your diet? Mark your intake level: None Little Moderate High Ninguna How much meat do you include in your diet? Mark your intake level: None Little Moderate High Ninguna How much fish do you include in your diet? Mark your intake level: None Little Moderate High Ninguna How much pasta or pizza do you include in your diet? Mark your intake level: None Little Moderate High Ninguna Do you usually smoke? If so, What is your intake level? None Little Moderate High Ninguna How much refined sugar (sweets, ice cream…) do you include in your diet? Mark your intake level: None Little Moderate High Ninguna How much fizzy drinks or refreshments do you include in your diet? Mark your intake level: None Little Moderate High Ninguna How much coffee or caffeine do you include in your diet? Mark your intake level: None Little Moderate High Ninguna How many alcohol do you include in your diet? Mark your intake level: None Little Moderate High Ninguna How much water do you consume daily?Mark your intake level: None Little Moderate High Ninguna If you are under any medication, please specify below what it is and what it is for: Emotional Stress Please, mark the areas where you may have or have had stress: Work Loss of a loved one Illness Relationship Other Nervous-muscular System Please, mark if you have or have had any of these conditions, or if you have discomfort in any of these areas: Headache Stiff neck Between the shoulders Shoulders, elbows, arms, wrist Thigh, calves, buttock Knee, ankle Whiplash Fractures Osteoporosis Arthritis Tendonitis Stiffness, tense muscles Lower back area Problems walking Discal herniation Sciatica Gastrointestinal System Please, mark if you have or have had any of these conditions or if you have discomfort in any of these areas : Diabetes Abdominal Pain Heartburn Constipation/diarrhoea Stomach ulcer Liver problems Gallbladder problems Weight problems Hemorrhoids Intestinal irritation Digestion of red meat Good Bad Ninguna Digestion of saturated fats Good Bad Ninguna Difficulty sleeping when you have dinner late Yes No Ninguna Difficulty sleeping if you have a hearty lunch/dinner: Yes No Ninguna Nervous System Please, mark if you have or have had any of these conditions or if you have discomfort in any of these areas : Vertigo / dizziness Depression Tingling/pins and needles in hands or feets Anxiety Insomnia / sleeplessness Migraine Epilepsy Fibromyalgia Weak immune System Vision / Hearing / Throat Please, mark if you have or have had any of these conditions or if you have discomfort in any of these areas : Vision disorders Eye pain Tinnitis Jaw Pain Otitis Sinusitis Throat Infections Respiratory and Cardiovascular System Please, mark if you have or have had any of these conditions or if you have discomfort in any of these areas : Chest Pain Asthma/ breathing difficulty Alergy Cardiac Problems Pulmonary Problems Cold feet / hands Cramps Low / High arterial pressure Slow / Fast Metabolism Genitourinary System Please, mark if you have or have had any of these conditions or if you have discomfort in any of these areas : Incontinence Bladder Problems Kidney Problems Urine infection Women Pregnant Menstruation problems Swollen ankle / feet Ninguna Men Prostate Problems Inguinal Hernia Impotence Ninguna Would you like to add any information about any of the above symptoms? You explicitly agree that your personal information compiled here will be stored in a file, called “Registro de Actividades del Tratamiento”. The person responsible for keeping your data secure is AYDEE MOSQUERA CAMBINDO, who will manage your data in relation to the chiropractic care provided. In any case, you have the right to exercise the rights of access, rectification, cancelation and opposition, by writing to AYDEE MOSQUERA CAMBINDO at the following address: C/ ASDRUBAL, 3 BAJO (30205 CARTAGENA, MURCIA) Email: info@centroquiropracticocartagena.com For further information, please consult our Privacy Policy. AGREE Ninguna Time's up
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