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Patient Info
Are You a Candidate?
Contact
About
Services
New Patient
Are You a Candidate?
Contact
This Survey Could Change Your Quality of Life
Complete This Survey to See if You Are a Candidate for Chiropractic Care
Please complete the questionnaire below. To see if you qualify by phone, please call our office at 931-591-7551
Candidate for Chiropractic Care
Please check any of the primary pain complaints you are experiencing
Neck
Low Back
Buttocks
Hip
Leg
Calf
Foot
Toes
How long have you had the pain?
Less than a month
1 to 6 months
6 months to a year
More than a year
Which best describes the frequency of your pain?
Intermittent (0-25% of day)
Occasional (26-50% of day)
Frequent (51-75% of day)
Constant (76-100% of day)
Have you already contacted a doctor about your pain?
Yes
No
Have you had back surgery?
Yes
No
Are you scheduled for back surgery?
Yes
No
Have you been diagnosed with any of these conditions?
Disc Herniation
Disc Bulge
Sciatica
Spinal Stenosis
Disc Degeneration
Spondylolisthesis
When does your condition and pain affect your activities?
While sitting
While standing
Trouble walking
Interrupted sleep at night
Decreased activities
Decreased pace
When is your pain at its worst?Describe how you feel and are affected
Describe how you feel and are affected
When was the last time you felt really great?
If there was a way to relieve your pain with one of our advanced, non-surgical treatment programs, are you interested in scheduling an appointment with our doctors?
Yes
No
What are the best times to contact you?
Morning
Afternoon
Evening
First Name
Last Name
Phone
Email
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