Check In Chiro

What is bothering you today?

headache

headache

neck

neck

L trap

left trap

right trap

right trap

upper back

upper back

mid back

mid back

low back

low back

left S.I.

left S.I.

right S.I.

right S.I.

Is your headache pain BETTER or WORSE since your last adjustment?*

Is your neck pain BETTER or WORSE since your last adjustment?*

Is your left trap pain BETTER or WORSE since your last adjustment?*

Is your right trap pain BETTER or WORSE since your last adjustment?*

Is your upper back pain BETTER or WORSE since your last adjustment?*

Is your mid back pain BETTER or WORSE since your last adjustment?*

Is your low back pain BETTER or WORSE since your last adjustment?*

Is your left S.I. pain BETTER or WORSE since your last adjustment?*

Is your right S.I. pain BETTER or WORSE since your last adjustment?*

Are you experiencing any radiating pain into your arms or hands?*

Yes
No

Are you experiencing any radiating pain into your legs or feet?*

Yes
No

Have you had any car accidents, surgeries, trauma or injuries since your last visit?*

Yes
No

Would you like to add a chair massage for $15 while you wait?

Yes
No

(If available) Note: Massage chair has a weight limit of 300 lbs.

In the last week, have you had a fever, a dry or painful throat, headache with sore throat, diarrhea, body aches or cough OR in the last 14 days have you been asked to self-isolate or quarantine by a doctor or had close contact or cared for someone diagnosed with COVID-19?*

Yes
No

When?*

Are you currently awaiting Covid-19 test results?*

Yes
No

PLEASE NOTE:

For the safety of everyone in this office, we ask that you please discontinue this check-in process and refrain from entering the office until you receive a negative test result.

Select the first letter of your FIRST Name

1st*

Select the first two letters of your LAST Name

1st*

2nd*