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How did you hear about us?Primary Care DoctorSpecialist DoctorUrgent CareHospitalERInsurance ProviderChiropractorSearch Engine (Google, Bing etc.)PatientRecommended by Friend or ColleagueMagazineMap Search3rd Party ReviewBlogSocial MediaOther

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What's bothering you? (check all that apply)(optional):

• Neck Pain
• Back Pain
• Arm or leg pain
• Tingling or numbness
• Headaches
• Second Opinion

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How much BACK pain are you experiencing on a scale from 0-10 with 0 being no pain & 10 being the worst? (optional)

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How much NECK pain are you experiencing on a scale from 0-10 with 0 being no pain & 10 being the worst? (optional)

0

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Is your pain related to an accident? (optional)

• Auto Accident
• Work Accident
• Fall or Other
• Not related to an accident

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Have you had any imaging tests? (optional)

• X-Ray(s)
• MRI(s)
• CT Scan(s)
• Other

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Have you seen any other doctors for this injury? (optional)

• Chiropractor
• Physical Therapist
• Orthopedics
• Family doctor
• Other

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