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Health Questionnaire

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Check all of the symptoms you have recently experienced:



Symptoms:
Arthritis
Asthma
Bunions
Fibromyalgia
Foot Pain / Plantar Fasciitis
Golf/Tennis Elbow
Groin Pull
Hamstring Pull
Hand Pain
Hip Pain
Knee Pain
Low Back Pain
Mid Back Pain
Migraines
Neck Neck Pain
Pain Between Shoulder Blades
Pinched Nerve
Poor Flexibility
Poor Posture
Pulled or Cramping Muscles
Recent Auto Accident
Rotator Cuff
Shin Splints
Shoulder Pain
Shoulder Tension
Tension / Headaches
Tingling/Numbness in Arms or Hands
Tingling/Numbness in Legs or Feet
TMJ (clicking or painful jaw)
Wrist / Carpal Tunnel
Which symptom is the worst?
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  American Family Chiropractic Centers
3011 S Lindsay Road Suite 101 | Gilbert, Arizona 85295
Tel: (480) 726-2287 | Fax: (480) 726-2131
Office Hours - call for appointment times
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