WE ARE
OPEN
& SEEING PATIENTS
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.
Submit
Thanks for Participating!