San Juan Holistic Healthcare Center
Patient Information:Name:__________________________________________________Today’s date______________________Address:___________________________________________City_______________State_____Zip________Home Phone_________________E-mail__________________________Date of birth___________________Name of Spouse or nearest relative_____________________________________Phone__________________Your Occupation____________________Your Employer________________SS#_______________________Referred to this office by friend/family member? If so, their name____________________________________Yellow pages_____ Mail_____ Clinic Location_____ Other________________________________________Payment for services wil be by cash_____ Check_____ Credit card_____ Health Insurance _______________Automobile Insurance _____ Worker’s compensation_____Name of Insurance Company____________________________Insured Employer______________________Insured’s Social Security number___________________________Employers phone number______________Are you covered by more than one insurance company? If so, name of insurance company________________Please list the symptoms that brought you here:1._______________________________________________________________________________________2._______________________________________________________________________________________3._______________________________________________________________________________________4._______________________________________________________________________________________5._______________________________________________________________________________________
Please mark your areas of pain or other symptoms:
Have you had these problems in the past? If so, when and how often:_____________________________________________________________________________________________________________________________________________________________________________________________________________Have you seen any other health professionals for these present symptoms? If so, who and when?_____________________________________________________________________________________________________________________________________________________________________________________Please list any other major illnesses or surgeries you have had:___________________________________________________________________________________________________________________________Please check any of the following symptoms you may be experiencing:Decreased energy/tired_____ Cold hand/feet_____ Women Only:Headaches_____ Sleep problems_____ PMS_____Depressed/Nervous_____ Weight concerns_____ Menstrual cramps_____Numbness/tingling anywhere_____ Allergies_____ Hot Flashes_____Dizziness_____ Digestive problems_____ Date of last menstrual cycle:Chronic pain_____ Ringing in ears_____ ______________________High blood pressure_____ Loss of concentration_____Diabetes or other blood sugar problem_____ Chronic fatigue_____Fibromyalgia_____ Other________________________________________________
Describe any injuries or accidents you have had in the past:1._______________________________________________________________________________________2._______________________________________________________________________________________3/_______________________________________________________________________________________What medications are you presently on and why:1._______________________________________________________________________________________2._______________________________________________________________________________________3._______________________________________________________________________________________4._______________________________________________________________________________________5._______________________________________________________________________________________6._______________________________________________________________________________________What vitamins are you taking and why:1._______________________________________________________________________________________2._______________________________________________________________________________________3._______________________________________________________________________________________4._______________________________________________________________________________________5._______________________________________________________________________________________6._______________________________________________________________________________________As a holistic healthcare practice, we are dedicated to helping you reach your health goals, so we ask that you take a moment and check your present health goals:_____Get out of pain_____Reaching optimum health and wellness_____Get out of pain, but I am interested in learning about wellness care and how it can improve my healthI understand that I am responsible for all charges incurred:________________________________________________________________________________________Name Date
