17264 Red Hill Ave,   Irvine ,  CA   92614 | Phone:  949-724-0011

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Our first priority is to bring you relief from any pain or discomfort!

Edlund Chiropractic P.C.


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.

WOULD YOU LIKE TO GET RID OF THE PROBLEM?  YES  NO

  

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