Have you consulted a chiropractor before?*
May we contact you at work?
1. The symptom(s) that have prompted me to seek care today include:*
2. And are the result of (darken circle):
2.a - An accident or injury*
2.b - A worsening long-term problem*
4. Intensity (How extreme are your current symptoms?)
5. Duration and Timing (When did it start and how often do you feel it?)*
6. Quality of symptoms (What does it feel like)*
7. Location (Where does it hurt?)*
If front, please provide more details
If back, please provide more details
8. Radiation (Does it affect other areas of your body? To what areas does the pain radiate, shoot or travel.)*
9. Aggravating or relieving factors (What makes it better or worse, such as time of day, movements, certain activities, etc.)
10. Prior interventions (What have you done to relieve the symptoms?)*
If other, please provide more information
11. What else should Dr. Gomez know about your current condition?*
12. How does your current condition interfere with your:
13. Review of Systems Chiropractic care focuses on the integrity of your nervous system, which controls and regulates your entire body. Please darken the circle beside any condition that you've Had or currently Have.
Past Personal, Family and Social History Please identify your past health history, including accidents, injuries, illnesses and treatments. Please complete each section fully.
PERSONAL
14. Illnesses (Check the illnesses you have Had in the past or Have now)*
If other, please provide more information
15. Operations (Surgical interventions, which may or may not have included hospitalization)*
If other, please provide more information
16. Treatments (Check the ones you've received in the Past or are receiving Currently)*
If Nutritional Supplements, please provide the list:
17. Injuries (Have you ever...)*
Medications (prescription and over-the-counter):*
FAMILY
18. Family History Some health issues are hereditary. Tell Dr. Gomez about the health of your immediate family members.
State Of Health (Sister 1)
State Of Health (Sister 2)
State Of Health (brother 1)
State Of Health (Brother 2)
19. Are there any other hereditary health issues that you know about?*
20. Social History
20.c - Prayer or Meditation*
20.f - Job Pressure / Stress*
20.o - Mercury Fillings?*
20.r - Recreational Drugs?*
21. Activities of Daily Living
21.c - Rising Out Of Chair*
21.h - Reaching Overhead*
21.j - Showering or Bathing*
21.q - Getting In/Out of Car*
21.u - Looking Over Shoulder*
21.w - Caring for Family*
26. Describe your typical eating habits:*
28. In addition to the main reason for your visit today, what additional health goals do you have?*