Go Chiro New Patient Forms

1
Date
Date
Year
Month
Day
2
Name* This field is required.
First Name
Last Name
3
🗓️ Date of Birth* This field is required.
4
📞 Phone Number* This field is required.
Area Code
Phone Number
5
May we text this number?* This field is required.
✅ Yes🚫 No
6
📧 Email Address* This field is required.
example@example.com
7
🧑‍⚕️ Biological Gender* This field is required.
Male
Female
8
🏠 Home Address* This field is required.This is your home address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
9
🤕 Which issue is your main complaint—the one you’d like to focus on first?* This field is required.
Neck Pain
Low Back Pain
Mid Back Pain
Sciatica
Shoulder Pain
Headaches/Migraines
Hip Pain
Knee Pain
TMJ/Jaw Pain
Numbness/Tingling in Arms or Legs
Other
10
Where is the discomfort* This field is required.
👉 Right
👈 Left
✋ Both
Other
11
🗓️ When did this issue start?* This field is required.
Just today
A few days ago
A few weeks ago
A few months ago
Over a year ago
Other
12
💬 Please describe what you were doing when you felt the pain.* This field is required.
13
⚡ How would you describe the feeling of this discomfort?* This field is required.Choose all that apply and click next
Sharp
Dull/Achy
Burning
Stabbing
Throbbing
Electric/Shocking
Numb/Tingling
Other
14
🔄 Does the pain spread to other areas?* This field is required.
✅ Yes🚫 No
15
Where does it radiate to?Choose all that apply and click next
head
jaw
neck
upper back
lower back
hip
shoulder
knee
elbow
hand
foot
Other
16
😐➡️😖 On a scale of 0-10, how would you rate the intensity of the discomfort?* This field is required.0 = no pain 5 = moderate pain 10 = worst pain
0
1
2
3
4
5
6
7
8
9
10
17
⏳ How often does it hurt?* This field is required.
approximately 90-100% of the time
approximately 75% of the time
approximately 50% of the time
approximately 25%.of the time
18
🕒 When do you notice this issue the most?* This field is required.Select all that apply
Morning
Afternoon
Evening
Overnight
No specific time
19
⚠️ What seems to make this issue worse?* This field is required.Choose all that apply and click next
Movement
Sitting
Standing
Lifting
Sleeping
Stress
Nothing in particular
Other
20
📈 Have you found anything that helps improve this issue?* This field is required.Choose all that apply and click next
Ice
Heat
Stretching
Chiropractic/Adjustments
Massage
Medications
Rest
Nothing really helps
Other
21
📜 Have you experienced this complaint in the past?* This field is required.
✅ Yes🚫 No
22
Since this issue started, have you noticed any of the following symptoms?* This field is required.If none apply, please select 'None of the above.
None of the above (✅ Required selection if no other option is chosen)
Bowel or bladder changes
Severe leg weakness
Difficulty swallowing
Dizziness or blackouts
Fever/chills
Unexplained weight loss
Night sweats
Unusual fatigue
Other
23
Do you have additional complaints?* This field is required.
✅ Yes🚫 NO
24
Where is your next complaint?
head
neck
upper back
lower back
sciatica
hip
shoulder
knee
elbow
TMJ
foot
hand
vertigo
Other
25
What best describes the discomfort?Choose all that apply and click next
sharp
sore
ache
burning
numbness/ tingling
stiffness
weakness
throbbing
tight
26
On a scale of 0-10, how would you rate the intensity of the discomfort? 0 = no pain 5 = moderate pain 10 = worst pain
0
1
2
3
4
5
6
7
8
9
10
27
How often does it hurt?
approximately 90-100% of the time
approximately 75% of the time
approximately 50% of the time
approximately 25%.of the time
28
What makes it worse?Choose all that apply and click next
sitting
standing
looking up
looking down
certain positions
laying face up
laying face down
work
exercise
physical activity
walking
running
bending
lifting
stairs
computer use
reaching
twisting
sneezing/laughing
driving
activity
Other
29
What makes it better?Choose all that apply and click next
treatment
rest
heat
standing
sitting
ice
heat
massage/rubbing
creams/gels
medication
stretching
activity
exercise
Other
30
Do you have any additional complaints?
✅ Yes🚫 NO
31
Please list any other complaints you may have.
32
Have you ever been diagnosed with any of these neurological conditions?* This field is required.Select all that apply or none
🧠 Stroke
⚡ Seizures
🔥 Neuropathy
🦠 Multiple Sclerosis
🌀 Parkinson’s
🚫 None of the above
Other
33
Have you ever been diagnosed with any of these heart or circulation conditions?* This field is required.Select all that apply or none of the above
❤️ High Blood Pressure
💔 Heart Disease
🩸 Blood Clots
⚡ Pacemaker or Defibrillator
🚫 None of the above
Other
34
Have you ever been diagnosed with any of these bone or joint conditions?* This field is required.Select all that apply or none of the above
🦴 Osteoporosis
🤕 Arthritis (Rheumatoid or Osteoarthritis)
🏥 Joint Replacement
🚫 None of the above
Other
35
Have you ever been diagnosed with any of these metabolic or autoimmune conditions?* This field is required.Select all that apply or none of the above
🍬 Diabetes
🦋 Thyroid Disorders
🔄 Lupus
🚫 None of the above
Other
36
Have you ever been diagnosed with any of these lung or breathing conditions?* This field is required.Select all that apply or none of the above
🌬️ Asthma
😮‍💨 COPD/Emphysema
🚫 None of the above
Other
37
Have you ever been diagnosed with cancer or any other condition not listed* This field is required.Select all that apply or none of the above
🎗️ Cancer
🚫 None of the above
Other
38
Please specify the type of cancer and treatment history
39
Do you use tobacco?* This field is required.
✅ Yes🚫 NO
40
Do you drink alcohol?* This field is required.
✅ Yes🚫 NO
41
Do you use marijuana or street drugs?* This field is required.
✅ Yes🚫 NO
42
Taking Anticoagulants? * This field is required.
✅ Yes🚫 NO
43
Severe unrelenting pain?* This field is required.
✅ Yes🚫 NO
44
Pain not relieved by rest?* This field is required.
✅ Yes🚫 NO
45
Urinary retention or incontinence?* This field is required.
✅ Yes🚫 NO
46
Bowel problems?* This field is required.
✅ Yes🚫 NO
47
Pain in both arms and both legs?* This field is required.
✅ Yes🚫 NO
48
Sudden weakness, numbness of face, arm or leg?* This field is required.
✅ Yes🚫 NO
49
Unexplained dizziness, unsteadiness, or sudden falls?* This field is required.
✅ Yes🚫 NO
50
Have you ever had any serious injuries, such as a car accident, fall, or sports injury?
✅ Yes🚫 No
51
Please describe any injury and when it occurredType or speak your answer
52
Have you ever had any surgeries or been hospitalized for a serious illness or injury?
✅ Yes🚫 No
53
Please list any surgeries or hospitalizations, along with the year they occurredType or speak your answer
54
Do you have any allergies?* This field is required.
✅ Yes🚫 NO
55
Please list any allergiesType or speak your answer
56
Are you on any medications?* This field is required.
💊 Yes🚫 No
57
Are you taking medications for any of the following?Check all that apply or select NONE
🩸 High Blood Pressure
🍬 Diabetes
🛢️ High Cholesterol
🦋 Thyroid Disorders
🌬️ Asthma / COPD
❤️ Heart Disease
🧠 Depression / Anxiety / Mental Health
🤕 Arthritis
🏥 Acid Reflux / Stomach Issues
🔥 Chronic Pain / Fibromyalgia / Neuropathy
Other not listed.
Other
58
High Blood Pressure (Hypertension) 🩸
Lisinopril
Amlodipine
Metoprolol
Losartan
Hydrochlorothiazide (HCTZ)
Atenolol
Carvedilol
Valsartan
Enalapril
Propranolol
Other
59
Diabetes 🍬Select other if none apply
Metformin
Insulin (Basaglar, Lantus, Humalog, etc.)
Jardiance
Ozempic
Trulicity
Glipizide
Glyburide
Farxiga
Rybelsus
Victoza
Other
60
High Cholesterol 🛢️Select other if none apply
Atorvastatin (Lipitor)
Simvastatin (Zocor)
Rosuvastatin (Crestor)
Pravastatin
Lovastatin
Ezetimibe (Zetia)
Alirocumab (Praluent)
Evolocumab (Repatha)
Bempedoic acid (Nexletol)
Fenofibrate
Other
61
Thyroid Disorders (Hypo-/Hyperthyroidism) 🦋Select other if none apply
Levothyroxine (Synthroid)
Armour Thyroid
Liothyronine (Cytomel)
Methimazole
Propylthiouracil (PTU)
Nature-Throid
NP Thyroid
Thyrolar
Tapazole
Radioactive Iodine Treatment
Other
62
Asthma / COPD 🌬️Select other if none apply
Albuterol (Ventolin, ProAir)
Advair (Fluticasone/Salmeterol)
Singulair (Montelukast)
Symbicort (Budesonide/Formoterol)
Spiriva (Tiotropium)
Breo Ellipta
Dulera
Combivent
Theophylline
Prednisone (for severe flare-ups)
Other
63
Heart Disease ❤️Select other if none apply
Aspirin
Clopidogrel (Plavix)
Nitroglycerin
Atorvastatin (Lipitor)
Metoprolol
Lisinopril
Warfarin (Coumadin)
Rivaroxaban (Xarelto)
Amiodarone
Digoxin
Other
64
Depression / Anxiety / Mental Health 🧠Select other if none apply
Sertraline (Zoloft)
Fluoxetine (Prozac)
Bupropion (Wellbutrin)
Escitalopram (Lexapro)
Duloxetine (Cymbalta)
Venlafaxine (Effexor)
Alprazolam (Xanax)
Clonazepam (Klonopin)
Quetiapine (Seroquel)
Aripiprazole (Abilify)
Other
65
Arthritis (Rheumatoid / Osteoarthritis) 🤕Select other if none apply
Ibuprofen (Advil, Motrin)
Naproxen (Aleve)
Celecoxib (Celebrex)
Methotrexate
Humira (Adalimumab)
Enbrel (Etanercept)
Remicade (Infliximab)
Tofacitinib (Xeljanz)
Prednisone
Hydroxychloroquine (Plaquenil)
Other
66
Acid Reflux / Stomach Issues 🏥Select other if none apply
Omeprazole (Prilosec)
Pantoprazole (Protonix)
Ranitidine (Zantac - discontinued but still asked about)
Esomeprazole (Nexium)
Famotidine (Pepcid)
Lansoprazole (Prevacid)
Sucralfate (Carafate)
Domperidone
Baclofen (for severe GERD)
Other
67
Chronic Pain / Neuropathy 🔥Select other if none apply
Gabapentin (Neurontin)
Pregabalin (Lyrica)
Tramadol
Duloxetine (Cymbalta)
Amitriptyline (Elavil)
Lidocaine patches
Hydrocodone (Norco, Vicodin)
Oxycodone (Percocet, OxyContin)
Topiramate (Topamax)
Naltrexone (Low Dose - LDN)
Other
68
Please list which other medications you are on and why
Huge
Large
Normal
Small
Ok
Ok
69
Have you been treated by any other healthcare provider for this condition?* This field is required.
YES🚫 NO
70
Whom did you see?
Primary Care
Physical Therapist
Orthopedic
Neurologist
Massage Therapist
Emergency Room/ Urgent Care
Other
71
Please list any additional health conditions, symptoms or concerns* This field is required.Type or speak your answer, choose next if no answer
Huge
Large
Normal
Small
Ok
Ok
72
What do you hope to achieve with chiropractic care?* This field is required.Mark all that apply
Reduce pain
Improve mobility
Prevent future issues
Return to work or daily activities
Improve athletic performance
Reduce reliance on medications
Improve posture
73
Has this issue affected any of the following?* This field is required.Select all that apply
💼 Work/Productivity
🏋️ Exercise
😴 Sleep
😟 Stress/Mood
👨‍👩‍👧‍👦 Family/Social Life
Other
74
What’s your goal for treatment?* This field is required.Select all that apply
Pain relief
Improved movement and flexibility
Increased strength/stability
Avoid surgery or injections
Improve posture
Return to work/sports/activities
Other
75
Health Insurance Portability and Accountability Act* This field is required.The full version of the terms are available at https://gochiromobile.com/forms/chiropractic-hipaa-policy
76
Financial & Cancellation Policy Agreement* This field is required.The full version of the terms are available at https://gochiromobile.com/forms/chiropractic-hipaa-policy
77
Signature* This field is required.
Should be Empty: