1. Which part of your body hurts?

lower back
upper back
neck
headache
shoulder pain
stomach ache
joint pain
hands and wrists
feet
other

2. On a scale of one to ten, with ten representing horrible pain and one representing slight discomfort, click on the degree of pain you feel right now:

1
2
3
4
5
6
7
8
9
10

3. Measured in months, estimate how long you have suffered this pain:

1-3 months
4-7 months
8-11 months
1 year
2-3 years
more than 3 years

4. If you have an idea of the cause of your pain, please use one or two words:

car accident      
sports injury      
work injury, including repetitive stress           
too  much body weight          
genetic cause
other:
___________________

Your name:
*required

Email address:
*required

Best phone number to reach you:


How did you hear about Chiropractic Associates?
web search
online yellow pages
yellow pages phone book
magazine or newspaper advertisement
other:

That’s it! Please click the “submit” button on your screen. Our seasoned chiropractic doctor will personally email you back within 24 hours with an initial assessment of your condition. If appropriate, we’ll schedule a first session for you to get fast relief for your pain. Thank you for taking care of your body!