Headache Yes No Neck or Back Pain Yes No Shoulder or Arm Pain Yes No Hip or Leg Pain Yes No Joint Pain Yes No Numbness, Tingling or Pins/Needles in Arms or Legs Yes No Chronic Pain Yes No Mucle Spasm or Tightness Yes No Been involved in an Auto Injury Yes No Been involved in a Work Injury Yes No Been involved in a Sports Injury Yes No Been involved in Other Injury Yes No If "Other Injury" (please explain): Has Injury Prevented You From Doing Anything in Your Life (please explain): Place Any Questions You Woul Like to Ask the Doctor Name * Address * Town * State * Zip Code * Home Phone * Work Phone * E-Mail * Birth Date * Male Yes No Female Yes No How Would You Like Us to Contact You? (Work phone, Home phone or Email) * Would You Like to Rate Our Website? (If so choose one from below) * Yes No Extremely Useful Yes No Very useful Yes No Slightly Useful Yes No Not Useful Yes No

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