Our first priority is to bring you relief from any pain or discomfort!
FREE STRESS SURVEY
Fill out our free survey to find out: Is stress negatively affecting your health?
Name
1. Check any of the following symptoms you have experienced in the past 6 months.
Low Back Pain
Shoulder Pain
Weight Trouble
Neck Pain
Hip Pain
Tension Across the Top of Shoulders
Pain Between Shoulder Blades
Knee Pain
Tingling/Numbing in Arms or Hands
Tension/Headaches
Ankle/Foot Pain
Tingling/Numbing in Legs or Feet
Tired or Fatigued
Ringing in the Ears
Dizziness
Wrist/Hand Pain
Allergies
Nervousness
Elbow Pain
Digestive Trouble
Difficulty Sleeping
Phone (Home)
* (Work)
Address *
City
* State, Zip
,>
Occupation
# Hours/Week Currently Working
Spouse’s Occupation
Age
Which one of the above symptoms is worst? How long have you had it?
When it is at its worst, how does it feel?
2. Indicate below how this causes you to act.
Moody Irritable Interrupts Sleep Restricted on daily activities Other
3. Indicate below how this affects you at work.
Decision Making Exhausted at end of day Decreased Productivity Poor Attitude Unable to work long hours Other
4. Indicate below how this affects your home life.
Patience with Spouse or Children Hinders Ability to Exercise or Participate in Sports Restricted Household Duties Interferes with ability to Participate in Hobbies or Other Desired Activities Other
If you have selected any of the above items then you could be suffering from EXCESSIVE STRESS, STRUCTURAL MISALIGNMENT or PINCHED NERVES. Chiropractic can help you because Chiropractic Doctors treat the body gently, naturally and without drugs to remove your stress and imbalances that CAUSE health problems.
I would like to come to the doctor’s office for a complimentary health evaluation. The evaluation includes consultation, complete spinal exam, computerized muscle scan (SEMG).
This will allow me to find out if I can be helped by Chiropractic without financial barriers.
Do you have insurance? Yes No HMO PPO
Click the submit button and receive a complementary health evaluation (Required fields *)
17264 Red Hill Ave, Irvine , CA , 92614 (see map) Phone: 949-724-0011 Fax: 949-724-0012