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Fields marked (*) are required

First Name:*


Last Name:*


Email:*


Sex (Male or Female):


Age:


Address:


City:


State:


Zip*:

Phone*:


Where Does it hurt?
(Check all the areas that are painful):
Head
Face
Wrist
Hand
Forearm
Neck
Abdomen
Shoulders
Pelvis
Middle Back
Lower Back
Knees
Hips
Thighs
Chest
Shins
Arm
Elbow
Ankle
Feet

Describe the most painful area:
(use a 0-10 pain scale, 0 being not painful and 10 being excruciating)


When did it start, and what makes it better or worse:


The reason for treatment is due to a:
Work
Auto
Athletic
Progressive
Unknown

Describe any condition that may be related
to your pain such as your general health:


Would you prefer our response to be by
phone or email:
Phone
Email

Describe treatments you have received and
medications that you are taking:


Do you have any of the following:
(if you don't know what it is, do not check the box)
Aortic Aneurysm
Spondylolisthesis
Moderate to Severe Osteoporosis
Pregnancy
Lumbar Spinal Fusion or Metal Hardware
Spinal or Pelvic Cancer
A Recent Low Back Fracture
Connective tissue
Believe