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

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:

Chemical Stress

How much fruits and vegetables do you include in your diet? Mark your intake level:

How many dairy products (milk, yogurt, cheese..) do you include in your diet? Mark your intake level:

How much bread, bakery, cereals or pastries do you include in your diet? Mark your intake level:

How much meat do you include in your diet? Mark your intake level:

How much fish do you include in your diet? Mark your intake level:

How much pasta or pizza do you include in your diet? Mark your intake level:

Do you usually smoke? If so, What is your intake level?

How much refined sugar (sweets, ice cream…) do you include in your diet? Mark your intake level:
How much fizzy drinks or refreshments do you include in your diet? Mark your intake level:
How much coffee or caffeine do you include in your diet? Mark your intake level:
How many alcohol do you include in your diet? Mark your intake level:
How much water do you consume daily?Mark your intake level:

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:

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:

Gastrointestinal System

Please, mark if you have or have  had any of these conditions or if you have discomfort in any of these areas :

Digestion of red meat
Digestion of saturated fats
Difficulty sleeping when you have dinner late
Difficulty sleeping if you have a hearty lunch/dinner:

Nervous System

Please, mark if you have or have  had any of these conditions or if you have discomfort in any of these areas :

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 :

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 :

Genitourinary System

Please, mark if you have or have  had any of these conditions or if you have discomfort in any of these areas :

Women
Men

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.