Health Survey

Purpose: To determine if any health problems you are having may be caused by stress. (* denotes required fields)

Name *
Age *
Phone (H)
Phone (W)
Address
City
State
Zip
Occupation
# Hours per week currently working

Check the box of any symptoms you have experienced in the last 6 months:

Low Back pain
Neck pain
Pain b/t shoulder
Tension/Headaches
Tired or fatigued
Wrist/hand pain
Elbow pain
Shoulder pain
Hip pain
Knee pain
Ankle/Foot pain
Ringing in ears
Allergies
Digestive issues
Weight trouble
Tension in shoulders
Tingling in the arms/hands
Tingling in the legs/feet
Dizziness
Nervousness
Difficulty sleeping

If you indicated that you experience any of the above symptoms, then you could be suffering from EXCESSIVE STRESS, STRUCTURAL MISALIGNMENT or PINCHED NERVES.

Chiropractic can help you because chiropractic doctors treat the body gently, naturally and without drugs to remove stress and imbalances that CAUSE health problems.

WOULD YOU LIKE TO GET RID OF THE PROBLEM? (Yes or No) *

If your answer is YES, there are several alternatives available to you. Please check the item most appropriate to you:

II would like to come to the doctor’s office for a complete evaluation. There is NO CHARGE for this examination. This will allow me to find out if I can be helped by chiropractic without any financial obligation.
I would like to come to a class on STRESS and WELLNESS.
I would like the doctor to call me to discuss my health problems before making an appointment.
Do you have insurance? (Yes or No) *

Verification:
Note: please type the verification exactly as you see it.