Skip to main content
Click To Call (303) 237-9617

Health Questionnaire

Give Us A Head Start On Your Health Condition

Fill out our Health Questionnaire below to give us a head start 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. 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
     
*
Security Image:
Security Code Image
* required information


Powered by ChiroPlanet.com  |  All Rights Reserved. Copyright 2024 ProfessionalPlanets.com LLC  |  Privacy Notice

Admin