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 your 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. 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 SYMPTOMS that apply to you:
Back or Neck Pain, Stiffness, Soreness
Headaches
Pain between the Shoulder Blades
Muscular Spasm and Tightness
Pain, Numbness or Tingling in Arms or Legs
Chronic Pain
Painful Joints
Excess Stress
Dizziness or Loss of Balance
Low Energy and Sluggishness
Any Other SYMPTOMS you may want to discuss:
Over the LAST 12 MONTHS have you been involved in: select all that apply
Auto Injuries
Work Injuries
Sports Injuries
Other Injuries
If "Other Injury", please explain:
How has your health condition IMPACTED YOUR LIFE? i.e. prevented you from doing?
* Name:
Street Address:
City:
State:
Zip:
Date of Birth:
Insurance Company Name:
Member I.D./Subscriber Number:
Provider Telephone Number:
* Email:
Phone:
* Preferred Contact Method?
Telephone
Email

*required information