We recommend that patients complete the intake form before their visits for faster service and so we can review it in advance of your appointment.

Option 1: Download the intake form and fill it out before your visit. Please email a completed form to drvictor@drgomezchiropractic.com or bring it with you when you come in!
Option 2: Fill out the electronic intake form as below so that we have it on hand for when you come in!

If your visit is due to an automobile accident, please do not complete this form. Call to schedule an appointment at (727) 916-0407 and we have specific forms to document your injuries.

DOWNLOAD INTAKE FORM

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CONFIDENTIAL HEALTH INFORMATION

Please allow our staff to photocopy your driver's license and insurance details. All information you supply is confidential. We comply with all federal privacy standards.

Today's Date*

Who may we thank for referring you?

Have you consulted a chiropractor before?*

Yes

If yes, When?

If yes, Whom?

Your Last Name*

Your Middle Name

Your First Name*

Gender*

Male

Female

Birth Date*

Marital Status*

Single

Married

Divorced

Widowed

Separated

Address*

City*

State/Province*

Zip/Postal Code*

Home Phone

Cell Phone*

Phone

Spouse's Name

Child's Name & Age

Email Address*

Emergency Contact*

Your Occupancy

Your Employer

Address

City

State/Province

Zip/Postal Code

Work Phone

May we contact you at work?

Yes

Insurance Carrier*

Policy Number

Primary Care Provider's Name*

Insured's Last Name*

First Name*

Middle Name

Birth Date*

Who carries this policy*

Self

Spouse

Parent

Insured's Employer

Employer's Phone

Address

City

State/Province

Zip/Postal Code

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*

Work

Auto

Other

None

If other, please provide more information

2.b - A worsening long-term problem*

Yes

2.c - An interest in:*

Wellness

Other

None

If other, please provide more information

3. Onset (When did you first notice your current symptoms?)*

4. Intensity (How extreme are your current symptoms?)

Absent: 0 - 3
Uncomfortable: 4 - 8
Agonizing: 9 - 10

5. Duration and Timing (When did it start and how often do you feel it?)*

Constant

Comes and goes

None

How Often?

6. Quality of symptoms (What does it feel like)*

Numbness

Tingling

Stiffness

Dull

Aching

Cramps

Nagging

Sharp

Buming

Shooting

Throbbing

Stabbing

Other

None

If other, please provide more information

7. Location (Where does it hurt?)*

Front

Back

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.)

9.a - What tends to worsen the problem?*

9.b - What tends to lessen the problem?*

10. Prior interventions (What have you done to relieve the symptoms?)*

Prescription medication

Surgery

lce

Over-the-counter drugs

Acupuncture

Heat

Homeopathic remedies

Physical therapy

Chiropractic

Massage

Other

None

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:

12.a - Work or career:*

12.b - Recreational activities:*

12.c - Household responsibilities:

12.d - Personal relationships*

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.

13.a - Musculoskeletal*

Had Osteoporosis

Have Osteoporosis

Had Arthritis

Have Arthritis

Had Scoliosis

Have Scoliosis

Had Neck pain

Have Neck pain

Had Back problems

Have Back problems

Had Hip disorders

Have Hip disorders

Had Knee injuries

Have Knee injuries

Had Foot/ankle pain

Have Foot/ankle pain

Had Shoulder problems

Have Shoulder problems

Had Elbow/wrist pain

Have Elbow/wrist pain

Had TMJ issues

Have TMJ issues

Had Poor posture

Have Poor posture

None

13.b - Neurological*

Had Anxiety

Have Anxiety

Had Depression

Have Depression

Had Headache

Have Headache

Had Dizziness

Have Dizziness

Had Pins and Needles

Have Pins and Needles

Had Numbness

Have Numbness

None

13.c - Cardiovascular*

Had High Blood Pressure

Have High Blood Pressure

Had Low Blood Pressure

Have Low Blood Pressure

Had High cholesterol

Have High cholesterol

Had Poor circulation

Have Poor circulation

Had Angina

Have Angina

Had Excessive Bruising

Have Excessive Bruising

None

13.d - Respiratory*

Had Asthma

Have Asthma

Had Apnea

Have Apnea

Had Emphysema

Have Emphysema

Had Hay Fever

Have Hay Fever

Had Shortness of Breath

Have Shortness of Breath

Had Pneumonia

Have Pneumonia

None

13.e - Digestive*

Had Anorexia/Bulimia

Have Anorexia/Bulimia

Had Ulcer

Have Ulcer

Had Food Sensitivities

Have Food Sensitivities

Had Heartburn

Have Heartburn

Had Constipation

Have Constipation

Had Diarrhea

Have Diarrhea

None

13.f - Sensory*

Had Blurred Vision

Have Blurred Vision

Had Ringing in Ears

Have Ringing in Ears

Had Hearing Loss

Have Hearing Loss

Had Chronic Ear Infection

Have Chronic Ear Infection

Had Loss of Smell

Have Loss of Smell

Had Loss of Taste

Have Loss of Taste

None

13.g - Integumentary*

Had Skin Cancer

Have Skin Cancer

Had Psoriasis

Have Psoriasis

Had Eczema

Have Eczema

Had Acne

Have Acne

Had Hair Loss

Have Hair Loss

Had Rash

Have Rash

None

13.h - Endocrine*

Had Thyroid Issues

Have Thyroid Issues

Had Immune Disorders

Have Immune Disorders

Had Hypoglycemia

Have Hypoglycemia

Had Frequent Infection

Have Frequent Infection

Had Swollen Glands

Have Swollen Glands

Had Low Energy

Have Low Energy

None

13.I - Genitourinary*

Had Kidney Stones

Have Kidney Stones

Had Infertility

Have Infertility

Had Bedwetting

Have Bedwetting

Had Prostate Issues

Have Prostate Issues

Had Erectile Dysfunction

Have Erectile Dysfunction

Had PMS Symptoms

Have PMS Symptoms

None

13.J - Constitutional*

Had Fainting

Have Fainting

Had Low Libido

Have Low Libido

Had Poor Appetite

Have Poor Appetite

Had Fatigue

Have Fatigue

Had Sudden Weight Change

Have Sudden Weight Change

Had Weakness

Have Weakness

None

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)*

Had AIDS

Have AIDS

Had Alcoholism

Have Alcoholism

Had Allergies

Have Allergies

Had Arteriosclerosis

Have Arteriosclerosis

Had Cancer

Have Cancer

Had Chicken Pox

Have Chicken Pox

Had Diabetes

Have Diabetes

Had Epilepsy

Have Epilepsy

Had Glaucoma

Have Glaucoma

Had Goiter

Have Goiter

Had Gout

Have Gout

Had Heart Disease

Have Heart Disease

Had Hepatitis

Have Hepatitis

Had Malaria

Have Malaria

Had Measles

Have Measles

Had Multiple Sclerosis

Have Multiple Sclerosis

Had Mumps

Have Mumps

Had Polio

Have Polio

Had Rheumatic Fever

Have Rheumatic Fever

Had Scarlet Fever

Have Scarlet Fever

Had Sexually Transmitted Disease

Have Sexually Transmitted Disease

Had Stroke

Have Stroke

Had Tuberculosis

Have Tuberculosis

Had Typhoid Fever

Have Typhoid Fever

Had Ulcer

Have Ulcer

Other

None

If other, please provide more information

15. Operations (Surgical interventions, which may or may not have included hospitalization)*

Appendix Removal

Bypass Surgery

Cancer

Cosmetic Surgery

Elective surgery

Eye surgery

Hysterectomy

Pacemaker

Spine

Tonsillectomy

Vasectomy

Other

None

If other, please provide more information

16. Treatments (Check the ones you've received in the Past or are receiving Currently)*

Past Acupuncture

Currently Acupuncture

Past Antibiotics

Currently Antibiotics

Birth Control Pills

Blood Transfusions

Chemotherapy

Chiropractic Care

Dialysis

Herbs

Homeopathy

Hormone Replacement

Inhaler

Massage Therapy

Physical Therapy

Nutritional Supplements

None

If Nutritional Supplements, please provide the list:

17. Injuries (Have you ever...)*

Had a fractured or broken bone

Had a spine or nerve disorder

Been knocked unconscious

Been injured in an accident

Used a crutch or other support

Had a body piercing

Used neck or back bracing

Received a tattoo

None

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.

Relative: Mother

Age - If Living (Mother)

State Of Health (Mother)

Good

Poor

N/A

Illnesses (Mother)

Age of Death (Mother)

Cause of Death (Mother)

Relative: Father

Age - If Living (Father)

State Of Health (Father)

Good

Poor

N/A

Illnesses (Father)

Age of Death (Father)

Cause of Death (Father)

Relative: Sister 1

Age - If Living (Sister 1)

State Of Health (Sister 1)

Good

Poor

N/A

Illnesses (Sister 1)

Age of Death (Sister 1)

Cause of Death (Sister 1)

Relative: Sister 2

Age - If Living (Sister 2)

State Of Health (Sister 2)

Good

Poor

N/A

Illnesses (Sister 2)

Age of Death (Sister 2)

Cause of Death (Sister 2)

Relative: Brother 1

Age - If Living (Brother 1)

State Of Health (brother 1)

Good

Poor

N/A

Illnesses (Brother 1)

Age of Death (Brother 1)

Cause of Death (Brother 1)

Relative: Brother 2

Age - If Living (Brother 2)

State Of Health (Brother 2)

Good

Poor

N/A

Illnesses (Brother 2)

Age of Death (Brother 2)

Cause of Death (Brother 2)

19. Are there any other hereditary health issues that you know about?*

20. Social History

20.a - Alcohol Use*

Daily

Weekly

None

20.b - How Much?*

20.c - Prayer or Meditation*

Yes

20.d - Coffee Use*

Daily

Weekly

None

20.e - How Much?*

20.f - Job Pressure / Stress*

Yes

20.g - Tobacco Use*

Daily

Weekly

None

20.h - How Much?*

20.i - Financial Peace?*

Yes

20.j - Exercising*

Daily

Weekly

None

20.k - How Much?*

20.l - Vaccinated*

Yes

20.m - Pain Reliever*

Daily

Weekly

None

20.n - How Much?*

20.o - Mercury Fillings?*

Yes

20.p - Soft Drinks*

Daily

Weekly

None

20.q - How Much?*

20.r - Recreational Drugs?*

Yes

20.s - Water Intake*

Daily

Weekly

None

20.t - How Much?*

Hobbies:*

21. Activities of Daily Living

21.a - Sitting*

N/A

No Effect
Mild Effect
Moderate Effect
Severe Effect
N/A

21.b - Grocery Shopping*

N/A

No Effect
Mild Effect
Moderate Effect
Severe Effect
N/A

21.c - Rising Out Of Chair*

N/A

No Effect
Mild Effect
Moderate Effect
Severe Effect
N/A

21.d - Household Chores*

N/A

No Effect
Mild Effect
Moderate Effect
Severe Effect
N/A

21.e - Standing*

N/A

No Effect
Mild Effect
Moderate Effect
Severe Effect
N/A

21.f - Lifting Objects*

N/A

No Effect
Mild Effect
Moderate Effect
Severe Effect
N/A

21.g - Walking*

N/A

No Effect
Mild Effect
Moderate Effect
Severe Effect
N/A

21.h - Reaching Overhead*

N/A

No Effect
Mild Effect
Moderate Effect
Severe Effect
N/A

21.i - Lying Down*

N/A

No Effect
Mild Effect
Moderate Effect
Severe Effect
N/A

21.j - Showering or Bathing*

N/A

No Effect
Mild Effect
Moderate Effect
Severe Effect
N/A

21.k - Bending Over*

N/A

No Effect
Mild Effect
Moderate Effect
Severe Effect
N/A

21.l - Dressing Myself*

N/A

No Effect
Mild Effect
Moderate Effect
Severe Effect
N/A

21.m - Climbing Stairs*

N/A

No Effect
Mild Effect
Moderate Effect
Severe Effect
N/A

21.n - Love Life*

N/A

No Effect
Mild Effect
Moderate Effect
Severe Effect
N/A

21.o - Using A Computer*

N/A

No Effect
Mild Effect
Moderate Effect
Severe Effect
N/A

21.p - Getting to Sleep*

N/A

No Effect
Mild Effect
Moderate Effect
Severe Effect
N/A

21.q - Getting In/Out of Car*

N/A

No Effect
Mild Effect
Moderate Effect
Severe Effect
N/A

21.r - Staying Asleep*

N/A

No Effect
Mild Effect
Moderate Effect
Severe Effect
N/A

21.s - Driving A Car*

N/A

No Effect
Mild Effect
Moderate Effect
Severe Effect
N/A

21.t - Concentrating*

N/A

No Effect
Mild Effect
Moderate Effect
Severe Effect
N/A

21.u - Looking Over Shoulder*

N/A

No Effect
Mild Effect
Moderate Effect
Severe Effect
N/A

21.v - Exercising*

N/A

No Effect
Mild Effect
Moderate Effect
Severe Effect
N/A

21.w - Caring for Family*

N/A

No Effect
Mild Effect
Moderate Effect
Severe Effect
N/A

21.x - Yard Work*

N/A

No Effect
Mild Effect
Moderate Effect
Severe Effect
N/A

22. What is the major stressor in your life?*

23. How much sleep do you average per night?*

How many hours?*

24. What is the type and approximate age of your mattress and pillow?*

25. What is preferred sleeping position?*

26. Describe your typical eating habits:*

Skip Breakfast

Two Meals A Day

Three Meals A Day

Snacking Between Meals

Other

27. What would be the most significant thing that you could do to improve your health?*

28. In addition to the main reason for your visit today, what additional health goals do you have?*

Acknowledgments

I instruct the chiropractor to deliver the care that, in his or her professional judgment, can best help me in the restoration of my health. I also understand that the chiropractic care offered in this practice is based on the best available evidence and designed to reduce or correct vertebral subluxation. Chiropractic is a separate and distinct healing art from medicine and does not proclaim to cure any named disease or entity.*

I may request a copy of The Privacy Policy and understand it describes how my personal health information is protected and released on my behalf of seeking reimbursement from any involved third parties.*

I realize that an X-Ray examination may be hazardous to an unborn child and I certify that to the best of my knowledge I am not pregnant.*

Date of last menstrual period (MM/DD/YYYY)

I grant permission to be called or texted to confirm or reschedule an appointment and to be sent occasional cards, letters, emails or health information to me as an extension of my care in this office.*

I acknowledge that any insurance I may have is an agreement between the carrier and me and that I am responsible for the payment of any covered or non-covered services I receive.*

To the best of my ability, the information I have supplied is complete and truthful. I have not misrepresented the presence, severity or cause of my health concern.*

If the patient is a minor child, print child's full name:

Signature*

Date*

2. And are the result of (darken circle):

9. Aggravating or relieving factors (What makes it better or worse, such as time of day, movements, certain activities, etc.)

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

FAMILY

20. Social History

21. Activities of Daily Living

Acknowledgments

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