Where is the source of your pain / tingling/ numbness?
*
Check all that apply
Neck
Back
Hip
Legs
Knee
Arms
Shoulder
Headache
Other
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
What types of treatments have you tried to relieve your pain?
*Check all that apply
Physical Therapy
Chiropractic Care
Acupuncture
Steroid Injections
Massage
Exercise
Pain Medication
What areas of your life is the pain affecting?
*Check all that apply
Relationships
Sleeping
Sitting for more than 1 hour
Walking/Exercise/Recreation
Job responsibilities
Household chores
Driving
Emotional well-being
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
Full Name
Email
Phone
Tap to Call 760-632-9736
Dr Neil Langschied
5120 Dixie Hwy
Suite 106
Louisville, KY 40216
Phone:
(502) 237-4740
The Chiropractic Wellness Center - 109 A S. Center Ave., Merrill, WI, 54452
(715) 539-7343
Copyright 2026. All Rights Reserved.
Privacy Policy
|
Terms of service
