Current Patient Chiropractic Forms
First Name
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Last Initial
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Describe why you are being seen. Please be specific WHERE you are having pain.
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Please rate your pain on a scale of 0 (no pain) – 10 (very severe)
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Please describe your symptoms (select all that apply)
Aching
Burning
Deep
Dull
Intolerable
Sharp
Shooting
Stabbing/throbbing
Stiffness
Tightness
Tingling
Numbness
Please mark on the image below where you're experiencing any pain
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Submit
Should be Empty: