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HEALTH SURVEY

Are you experiencing pain or discomfort in any of the following areas? (Chief Complaint)

Shoulder

Neck

Foot/Ankle

Muscle Spasm

Sciatica

Upper Back

Bunions

Numbness/Tingling

TMJ (Lock Jaw)

Mid Back

Flat Feet

Hammer Toes

Posture Problems

Headaches

Low Back

Carpal Tunnel

Heel Spurs

Hip/Leg

Radiating Disc Problem or Pain

Are you interested in any of the following areas of wellness?

Acupuncture/Cupping Therapy/Massage

Nutrition/Healthy Food

Dental Care

Skin Care/ Anti Aging Products

Vitamins/Minerals/Supplements

All information in this survey is confidential and will not be sold to third parties. Please note that filling out this survey, you understand that you are willingly participating in our event and that your employer bears no responsibility for any pain or injuries sustained from this event. Your name and Last Name Initial serves as e-Signature.

Thanks for Participating!