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Please fill out the form below and the doctor will contact you as soon they can.

Name:
E-mail: (required)
Address:
City:
State:
Zip:
Home Phone:
Age:
Occupation:
Number of Children:
Do you have trouble relaxing or falling asleep?
Yes No
Are you exhausted at the end of the day?
Yes No
Do you have weight problems?
Yes No
     
if so, are you underweight?
Yes No
     
overweight?
Yes No
Do you take pain relievers, antacid, tranquilizers, or any other relief oriented medicine?
Yes No
Do you exercise less than two times weekly?
Yes No
Do you feel you are a nervous or tense person?
Yes No
Do you lose your temper or become angry easily?
Yes No
Do you rely on caffeine or sugar stimulants?
Yes No
Have you ever had an auto accident or been injured on the job?
Yes No
Do any members of your immediate family have back and/or neck problems?
Yes No
Do you have any other health problems of which you are aware?
Yes No
If yes, explain and list any medications you are currently taking.
Please mark any and all areas of pain and/or discomfort for the items below.

Past

Present
Low Back Pain

Leg Pain

Neck Pain

Shoulder and Arm Pain

Disc Problems

Whiplash Neck Injuries

Arthritis

Pinched Nerve

Headache

Scoliosis

Dizziness

Numbness or Tingling in Arms or Legs

Menstrual Pain

Sinus or Allergies

Do we have permission to call you about your survey?
 Yes No
If you live outside Portland, would you like us to put you in touch with a chiropractor in your area?
 Yes No
N/A




1500 Wildcat Dr., Ste. F
Portland, TX 78374
Ofc: (361) 643-BACK
Alt: (361) 364-0775