patient-form

Fill out the form below as completely as possible and click the submit button to view your test results







Check all of the following symptoms you have experienced in the past 6 months :

 Low Back Pain Shoulder Pain Wrist / Carpal Tunnel Neck Pain Hip Pain Arthritis Pain Between Shoulder Blades "Pinched Nerve" Rotator Cuff Auto Accident (last 3 months) Tension Across the Top of Shoulders TMJ (clicking or painful jaw) Tension / Headaches Tingling / Numbness in Arms or Hands Poor Flexibility
 Migraines Tingling / Numbness in Legs or Feet Fibromyalgia Mid Back Pain Foot Pain / Plantar Fascitis Knee Pain Pulled or Cramping Muscle Poor Posture Asthma Bunions Hand Pain Shin Spints Goin Pull Hamstring Pull Golfer Elbow / Tennis Elbow


Would you like to get rid of it? :


What have you done proactively to resolve the symptom :


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