E-Consultation

Check any of the following symptoms that apply to you:

Symptoms:
Back or Neck Pain, Stiffness or Soreness
Headaches
Pain between the Shoulder Blades
Muscular Spasm and Tightness
Pain, Numbness or Tingling in Extremities
Difficulty Sleeping
Chronic Pain
Painful Joints
Excess Stress
Dizziness or Loss of Balance
Low Energy and Sluggishness
Difficulty Working

Over the past 12 months have you been involved in: (select all that apply)


Injuries:
Automobile Accident Injuries
Work Injuries
Sports Injuries
Other Injury
If other, please explain:
Is this a new problem?
Yes
No
Has this problem developed over many years?
Yes
No
Do you suffer with this problem frequently?
Yes
No
Have you received previous treatment?
Yes
No
Is your problem getting worse?
Yes
No
Are you currently on medication?
Yes
No
Have you had surgery?
Yes
No
How has your health condition impacted your life? (prevented you from doing)

What health goals have you set for yourself recently or would you now like to set?

(select all that apply)

Goals:
To initiate or improve upon a fitness/exercise program
To decrease pain
To increase energy
To improve my immune system
To participate in a preventative health plan to increase overall health and well-being
Other
Other Goals:

Children 1-10 years of age


Does your child have difficulty walking?
Yes
No
Does your child wet the bed?
Yes
No
Does your child have allergies?
Yes
No
Does your child have darkness under the eyes?
Yes
No
Does your child have recurring ear infections?
Yes
No
Does your child have tubes in the ears?
Yes
No
Does your child have difficulty concentrating?
Yes
No
Does your child have growing pains?
Yes
No

Complete the area below if you would like us to check your insurance coverage:


Health Insurance Company:
Insurance ID Number:
Subscriber ID:
Group or Plan Number:
Provider Phone Number:
Please include any additional information:

Tell us more information about you:


* First Name:
* Last Name:
* Street Address:
* City:
* State:
* Zip Code:
* Email Address:
* Telephone:
* Date Of Birth:
* Sex:
Male
Female
How should we contact you?
Telephone
Email
Would you like to setup an appointment?
Yes
No
How did you hear about us?
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