Shoulder Pain Hip Pain Knee Pain Ankle / Foot Pain Ringing in the ears Allergies Digestive Troubles
Weight Trouble Tension Across the Top of Shoulders Tingling / Numbing in Arms or Hands Tingling / Numbing in Legs or Feet Dizziness Nervousness Difficulty Sleeping
Which one of the above symptoms is worse? How long have you had it? When it is at its worst, how does it feel? II. Check how this causes you to act: Moody Irritable Interrupts Sleep Restricted on daily activities Other III. How this bothers you at work: Decision Making Exhausted at End of Day Decreased Productivity Poor Attitude Unable to Work Long Hours Other Other IV. How this hinders your life: Lose patience with spouse or children Hinders ability to exercise or participate in sports Restricted household duties Interferes with ability to participate in hobbies or other desired activities Other If you circled any of the above items 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 your stress and imbalances that CAUSE health problems. WOULD YOU LIKE TO GET RID OF THE PROBLEM? Yes No If your answer is YES there are several alternatives available to you. Please select the item most appropriate for you: 1) I 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 barriers. 2) I would like to come to a class on STRESS and WELLNESS. 3) I would like the Doctor to call me to discuss my health problems before making an appointment.
Do you have insurance? Yes No HMO? Yes No
