Chiropractic Questionnaire

Please fill out the following form to help us understand your physical condition.

First Name

Email Address

Last Name

Date of Birth

Check one of the following symptoms you have been experiencing: *

Headaches

Neck Pain

Low-Back Pain

TMJ(D) Pain

Hip Pain

Tired/Fatigued

Pain Between the Shoulders

Extremity Pain(s) - Shoulder

Numbness/Tingling

PMS

Other

Which symptom above is the worst? What secondary/other symptoms are you having?

Did your health problems begin after you were: *

In an Auto Accident

In a Work Injury

Sleeping

Excessive Sitting

Under Emotional Stress

Pregnancy

Doing Sports/Working Out

Lifting

Unknown/Not Sure

How long have you had it? When it is at its worst, how does it feel?

Today's Date

I WANT TO GET RID OF THE PROBLEM. PLEASE CONTACT ME.

Thanks for submitting!

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