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?*Selectbetterworsethe sameIs your neck pain BETTER or WORSE since your last adjustment?*Selectbetterworsethe sameIs your left trap pain BETTER or WORSE since your last adjustment?*Selectbetterworsethe sameIs your right trap pain BETTER or WORSE since your last adjustment?*Selectbetterworsethe sameIs your upper back pain BETTER or WORSE since your last adjustment?*Selectbetterworsethe sameIs your mid back pain BETTER or WORSE since your last adjustment?*Selectbetterworsethe sameIs your low back pain BETTER or WORSE since your last adjustment?*Selectbetterworsethe sameIs your left S.I. pain BETTER or WORSE since your last adjustment?*Selectbetterworsethe sameIs your right S.I. pain BETTER or WORSE since your last adjustment?*Selectbetterworsethe sameAre 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?* Select the first letter of your FIRST Name1st*SelectABCDEFGHIJKLMNOPQRSTUVWXYZSelect the first two letters of your LAST Name1st*SelectABCDEFGHIJKLMNOPQRSTUVWXYZ2nd*SelectABCDEFGHIJKLMNOPQRSTUVWXYZ