Please Check any of the following symptoms that apply to you:
Back Pain Neck Pain Stiffness or Soreness Headaches Pain between the Shoulder Blades Muscular Tightness Numbness or Tingling Chronic Pain Painful Joints Stress Dizziness or Loss of Balance Low Energy
Over the Last 12 months have you been involved in: Select all that apply:
Fall Down or Slip on the Floor Auto Injury Work Injury Sports Injury Other Injuries
If Other Injury, Please Explain:
How has your Health condition impacted your life or daily activities? i.e. prevented your from doing?
Please ask any concerns or questions that you would like to ask the doctor here:
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