Consultation | SpinalAidForRecovery

Consultation Form

Please take a moment to fill out the form.

First Name

Last Name

Phone number:

Address

Birthday

Profession

Where do you feel symptoms/pain/discomfort? How would you rate it on a 1-10 scale the intensity of it?

When and how did it started?

In your lifetime have you had any of the following treatmens

Massage

Chiropractic

Physio

Something else

Please describe if something else other then above

Have you had any surgeries?

Have you had any fractures?

Have you had cancer?

Do you have any auto immune disease?

Have you had any motor vehicle accidents? If so please tell also how long ago it happened.

Have you had any falls?

Do you take any medications?

Have you had any vaccination within the last 6 months?

What model of car do you drive?

How many pillows do you typically sleep over night?

What type of mattress do you have? How firm is it?

Are you experiencing any stress due to family or work?

How would you rate your pain threshold on a 1-10 scale?

Would you rather be called on the phone or via email? In case of phone what time of the day suit you to be called?

Your Signature

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