To determine if chiropractic care is right for you, start by filling out the form with your basic information. Then, answer a few questions about your symptoms and how they affect your daily life. This will help us understand your needs and provide personalized recommendations for your care.

Full Name *

Email *

Phone *

Captcha

Check off any of the following symptoms you have experienced in the past 6 months (Check more than one if necessary to describe your problem) *

Headaches/Tension

Allergies

Neck Pain

Hip Pain

Dizziness

Shoulder Pain

Ankle Foot Pain

Low Back Pain

Fatigue, tired

Knee Pain

Wrist/Hand Pain

Digestive Disturbance

Difficulty Sleeping

Irritability

Weight Trouble

Pain Between Shoulder Blades

Numbing/Tingling in Arms/Hands

Pain Anywhere in Body

Tension Across Top Of Shoulders

Elbow Pain

Numbing/Tingling in Legs/Feet

Ringing in Ears

Other

What daily activities are affected by your pain or condition? (Check more than one if necessary to describe your problem) *

Sleep

Walking

Sitting

Hobbies

Leisure

Work

Excercise

Other

How would you rate the severity of your problem on a scale of 1 to 10, with 1 being the best and 10 being the worst? *

Do you take over the counter or prescription medications? *

Yes

How many over the counter or prescription pills do you take in a week? *

Average of over the counter or prescription medications you take in a year

How long have you been experiencing your symptoms? *

Less than a Month

1-3 Months

4-7 Months

8-12 Months

More than 1 year

None

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