Healing Insights: Chiropractic Symptom Survey

Where is your primary area of pain or discomfort?

Neck Back Shoulders Hips Legs

How would you describe the pain?

Sharp Dull Throbbing Pins and needles Numbness

When did the pain or discomfort start?

Less than a week ago 1-4 weeks 1-3 months More than 3 months Chronic condition

What aggravates the pain?

Movement Sitting Standing Exercise No specific trigger

Have you experienced any recent injuries?

Yes No

How does the pain affect your daily activities?

Severely limits Moderately affects Minor inconvenience No impact Prevents normal function

All set, how can we reach you?

Name

Phone

Sign up to receive updates, special offers, newsletters and other marketing messages from us. You can withdraw consent any time.

Thanks for stopping by!

We will be in touch shortly.

Great, got your response!

Thank you

Your responses guide us towards your optimal health!