Patient Intake Form
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1McDuff Chiropractic Center
3075 Citrus Circle, Suite 175 Walnut Creek, CA 94598
Patient Intake Form
Last Name:__________________________
First Name:______________________
MI:_____ Date of birth:___/___/_____
Sex: M F
Social Sec. # ____________________
Weight:__________
Height:__________
Name Suffix: Jr. Sr.
Marital Status: check one ___Married ___Single ___Other
Preferred Language:_____________________
Smoking: check one
___Current everyday smoker
Smoking Start Year:____________
___1 Pack a day
___Current some day smoker
Smoking End Year:____________
___2 Packs a day
___Former smoker
Frequency: check one
___2 ½ Packs a day
___Heavy tobacco smoker
___1 – 5
___3 or more packs a day
___Light tobacco smoker
___6 – 10
___Never smoked
___½ Pack a day
Race: check one
Ethnicity: check one
___American Indian or
___Native Hawaiian or Other Pacific
___Cuban
Alaska Native
Islander
___Declined to Disclose
___Asian
___Other Asian (example Hmong,
Laotian, Thai)
___Hispanic or Latino
___Black or African
___Other Pacific Islander (example
American
___Mexican, Mexican American,
Fijian, Tongan)
___Chinese
Chicano
___Other Race
___Not Hispanic or Latino
___Declined to Disclose
___Prohibited by law
___Prohibited by Law
___Filipino
___Samoan
___Puerto Rican
___Guamanian or Chamorro
___Vietnamese
___Unknown
___Japanese
___White
___Korean
Street Address:________________________________
City:_____________________
State:_____
Zip:___________
Home Phone:________________________
Work Phone:________________________
Cell Phone:_____________________
Email:________________________________________________
Insurance Information:
Secondary Insurance Information:
Insurance Co:_______________________________________
Insurance Co:_______________________________________
Primary Insured:____________________________________
Primary Insured:____________________________________
Patient Relationship to Primary: circle one
Patient Relationship to Primary: circle one
Self
Spouse Child
Other Relationship
Self
Spouse Child
Other Relationship
Subscriber ID:______________________________________
Subscriber ID:______________________________________
Group #:___________________________________________
Group #:___________________________________________
Plan Name:_________________________________________
Plan Name:_________________________________________
Deductable:________________________________________
Deductable:________________________________________
Visit Co-payment:___________________________________
Visit Co-payment:___________________________________
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Parent category: Business