925-395-0252

Thanks For Scheduling Your Appointment

In order for us to best prepare for your appointment, please complete the brief survey below

On a scale of 1-10, one being hardly any pain and ten being excruciating, how would you rate your pain?

Where is the source of your pain? Choose all options that apply.

Neck

Back

Knee

Shoulder

Arms

Legs

Headache

Other

What type of doctors have you seen? Choose all options that apply.

Chiropractor

Pain Management

Neurologist

Orthopaedic Surgeon

General/Family Doctor

Other

None

How did the pain begin? Choose all options that apply.

Accident at home

Vehicle accident

Accident at work/work related

It just began

After surgery

Came on gradually

Sports related

Other

Have you had any surgeries to your existing pain or any other pain condition?

Yes

What areas of your life are affected by the pain? Choose all options that apply.

Maintaining a safe environment

Communication

Breathing

Eating & drinking

Washing & dressing

Mobilization

Working & playing

Expressing sexuality

Sleeping

Daily parenting

Finances

Household chores

Self worth/value

Physical well-being

Emotional health

Other

How committed are you to fixing your pain TODAY?

Very committed

Very committed
Somewhat committed
Neutral
Not ready to commit yet
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Which insurance (if any) do you have? (We are NOT a Medicaid provider)

Aetna

Blue Cross/Blue Shield
United Healthcare
Cigna
Aetna
Humana
Medicaid
Medicare
Cash/Out of pocket
Other
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Zip Code

PLEASE ACKNOWLEDGE THE FOLLOWING STATEMENT: I will NOT miss my appointment once it is scheduled and confirmed because I respect your time and I understand it's not fair to others who would schedule in my place if I don't show up.

Yes

PLEASE ACKNOWLEDGE THE FOLLOWING STATEMENT: I understand that the office is located at [UPDATE WITH LOCATION].

Yes

PLEASE ACKNOWLEDGE THE FOLLOWING STATEMENT: I am serious about my health and I will use my voucher before it expires in 5 days.

Yes

First Name

Last Name

Email *