ASK THE DOCTOR - COMPLIMENTARY CONSULTATION

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. (note: there are no out of pocket expense for most work-related and automobile accident injuries.)

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 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

 Over the last 12 months have you been involved in: select all that apply
Auto Injuries
If "Other Injuries", please explain:
Work Injuries
Sports Injuries
Other Injuries

 How has your health condition impacted your life?

 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 Other:
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

 Place questions and concerns you would like to ask the doctor here.

 Complete the area below if you would like us to check your insurance coverage:
Health Insurance Company
Subscriber ID
Group or Plan Number
Phone Number
If the information on your health card does not match the above or there is additional information, please include it below


Give us some information about yourself.
Name
Street Address
City   State    Zip
Email
Work Phone
Home Phone
Age male female
How should we contact you    home work email

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