Chiro Assessment Quiz
What is the level of pain you are experiencing? (10 being the most severe)
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What is the level of pain you are experiencing? (10 being the most severe)
1
2
3
4
5
6
7
8
9
10
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Where is the source of your pain? (check all that apply)
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Back
Neck
Knee
Shoulder
Arms
Legs
Headache
Other
How did the pain begin? (Check all that apply)
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Accident at Home
Vehicle Accident
Accident at Work
"Came on Gradually"
After an illness
Sports Related
Other
What type of doctors have you seen for your pain? (Check all that apply)
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Chiropractor
Pain Management
Neurologist
Orthopedic Surgeon
General / Family Doctor
Other
none
Have you had any surgeries related to your existing pain or any prior pain conditions?
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Have you had any surgeries related to your existing pain or any prior pain conditions?
Yes
No
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Do you have any type of health or medical insurance?
Do you have any type of health or medical insurance?
Yes
No
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Full Name
Email
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Phone
*
Postal code
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