Health Questionnaire, Can We Help You?

Give Us A Few Moments Regarding Your Current Health Condition

Please fill out our Health Questionnaire below to give us a better idea on your current health condition. When you're done, simply indicate whether you'd like us to contact you by phone or e-mail to discuss your health plan options as well as explore the possibility of scheduling you for a consultation and examination.

Health Insurance Coverage Questions?

We will gladly contact your health insurance company to determine the extent of chiropractic health coverage you have with our office. Please also see our section explaining insurance, with answers to the most commonly asked questions. The section on insurance, also contains a handy guide for all the plans that we are a Preferred Provider. Simply include the information in the appropriate form fields below.

Your Confidentiality Is Important To Us

Any and all information submitted is and will remain confidential.


Check any of the following SYMPTOMS that apply to you:

Back or Neck Pain, Stiffness, Soreness

Headaches

Pain between the Shoulder Blades

Muscular Spasm and Tightness

Pain, Numbness or Tingling in Extremities

Chronic Pain

Painful Joints

Excess Stress

Dizziness or Loss of Balance

Low Energy and Sluggishness

Over the LAST 12 MONTHS have you been involved in: select all that apply

Auto Injuries

Other Injury

Work Injuries

Sports Injuries

If "Other Injury", please Explain:



How has your health condition IMPACTED YOUR LIFE? i.e. prevented you from doing?



What HEALTH GOALS have you set for yourself recently or would you now like to set? check all that apply

To initiate or improve upon a fitness/exercise program

To lose excess body fat

To build extra muscle

To consume a healthier, more nutritious diet

To participate in a preventative health plan to increase overall health and well-being

Other:



Place QUESTIONS & CONCERNS you would like to ask the doctor here.



Provide us with your CONTACT INFORMATION. (all submitted information is kept confidential)

*Name:

Address

City:State: Zip:

*Email:

Phone:

Age: Gender: male female

*Contact Via: Home Telephone Work Telephone E-Mail

*Site Rating: Extremely Useful Very Useful Slightly Useful
Not Useful

*required information

                           
Southmetro Chiropractic Center
Design by 2505Studios.com