Health Survey

 Please complete the following form if you would like to be contacted by a doctor of chiropractic. To assist the doctor we kindly ask that you be as thorough as possible. If you would like to schedule an initial consultation, please call the clinic at: (316) 722-5555. Thank you.

Name                Age

Street

City State Zip Phone Work

Male Female Occupation

Email    

Please mark any of the following that apply to you.

Is your condition related to an automobile accident?
Is your condition related to an accident that occurred at work?
Has the pain changed your quality of life?

Headaches     Neck Pain        Low Back Pain Joint Pain
Fatigue       Nervousness      Dizziness     Pain Between Shoulder Blades
Weakness      Numbness         Tingling      Tension Across Top of Shoulders
Irritability  Trouble Sleeping Allergies     Digestive Problems
 

Which of the above bothers you the most?
How long have you been bothered by this condition?
Please include any additional comments or information regarding your condition here.

CHIROPRACTIC CAN HELP YOU because Chiropractic Doctors gently treat the body, naturally, without drugs to remove the stress and imbalances that CAUSE health problems.

Would you like to get rid of your health problem? Yes No

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