Health Questionnaire


Give Us A Head Start On Your Health Condition

Fill out our Health Questionnaire below to give us a head start on your current health condition. When you're done, simply indicate whether you'd like us to contact you by phone or e-mail to discuss your health plan options as well as explore the possibility of scheduling you for a consultation and examination.

Health Insurance Coverage Questions?

We will gladly contact your health insurance company to determine the extent of chiropractic health coverage you have with our office. Simply include the information in the appropriate form fields below.

Your Confidentiality Is Important To Us

Any and all information submitted is and will remain confidential.

Check any of the following
Back or Neck Pain, Stiffness, Soreness
Chronic Pain
Headaches
Painful Joints
Pain between the Shoulder Blades
Excess Stress
Muscular Spasm and Tightness
Dizziness or Loss of Balance
Pain, Numbness or Tingling in Extremities
Low Energy and Sluggishness
Other
If "Other Injury", please Explain:




Over the LAST 12 MONTHS have you been involved in: select all that apply
Auto Injuries
Work Injuries
Sports Injuries
Other Injury
If "Other Injury", please Explain:




How has your health condition IMPACTED YOUR LIFE? i.e. prevented you from doing?




What HEALTH GOALS have you set for yourself recently or would you now like to set? check all that apply
To initiate or improve upon a fitness/exercise program
To lose excess body fat
To build extra muscle
To consume a healthier, more nutritious diet
To participate in a preventative health plan to increase overall health and well-being
Other:
If "Other Injury", please Explain:




Provide us with your CONTACT INFORMATION. (all submitted information is kept confidential)



* Name:
Address
City
State:
Zip:
* Email:
Phone:
Gender
Male
Female
* Contact Via:
Home Telephone
Work Telephone
E-Mail
Enter Verification Characters:

Captcha

* required information