New Patient Special at Kowalik Family Chiropractic

On a Scale of 0 - 10 what is your level of pain?

(0 = No Pain, 10 = It can't get any worse)

0

1

2

3

4

5

6

7

8

9

10

Is the pain / tingling / numbness:

*Choose ONLY 1

Rapidly getting better

Fluctuating but getting better

Seems to be getting better but improvement is slow

Neither getting better or worse

Gradually getting worse

Rapidly getting worse

How committed are you to fixing this pain TODAY?

*Choose ONLY 1

Very committed

Somewhat committed

Neutral

Not ready to commit yet

Where is the source of your pain / tingling/ numbness?

**Check all that apply*

On a Scale of 0 - 10 what is your level of pain?

(0 = No Pain, 10 = It can't get any worse)

What types of treatments have you tried to relieve your pain?

*Check all that apply

What areas of your life is the pain affecting?

*Check all that apply

Is the pain / tingling / numbness:

*Choose ONLY 1

How committed are you to fixing this pain TODAY?

*Choose ONLY 1

Full Name

Email

Phone

Dr Neil Langschied

5120 Dixie Hwy

Suite 106

Louisville, KY 40216

Phone: (502) 237-4740

Kowalik Family Chiropractic - 23731 El Toro Rd, Suite C, Lake Forest, CA 92630 (949) 264-5696

Copyright 2024. All Rights Reserved.

Privacy Policy | Terms of service

Where is the source of your pain / tingling/ numbness?

*Check all that apply

On a Scale of 0 - 10 what is your level of pain?

(0 = No Pain, 10 = It can't get any worse)

What types of treatments have you tried to relieve your pain?

*Check all that apply

What areas of your life is the pain affecting?

*Check all that apply

Is the pain / tingling / numbness:

*Choose ONLY 1

How committed are you to fixing this pain TODAY?

*Choose ONLY 1

Full Name

Email

Phone

Dr Neil Langschied 5120 Dixie Hwy Suite 106 Louisville, KY 40216 Phone: (502) 237-4740

Kowalik Family Chiropractic - 23731 El Toro Rd, Suite C, Lake Forest, CA 92630 (949) 264-5696

Copyright 2024. All Rights Reserved.

Privacy Policy | Terms of service

**Check all that apply*

Dr Neil Langschied

5120 Dixie Hwy

Suite 106

Louisville, KY 40216

Phone: (502) 237-4740