Office Profile
About our Associates
Health Survey
New Patient Forms
Spinal Decompression
Services
Product Catalog
FAQ
Health Links
Photo Gallary
Directions to IMC, PA
Patient Privacy
E-mail Us
 
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


|Office Profile| |About our Associates| |Health Survey| |New Patient Forms| |Spinal Decompression| |Services| |Product Catalog| |FAQ| |Health Links| |Photo Gallary| |Directions to IMC, PA| |Patient Privacy| |E-mail Us|


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