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Screening Survey – Atchley Chiropractic Centers – Prosper

by | Aug 4, 2022

Displaying 1 - 25 of 81

Screening DateNameEmailPhoneAppointment DateAppointment TimeNOTES: (office use only)Recently Experienced Symptoms:
04/29/2023Chloe ClementeEmail hidden; Javascript is required.(951) 396-095105/01/202304:30 PM

10/01/2001
Paid $20 Square

  • Back Pain
  • Neck Pain
  • Sinus/Allergies
  • Headaches/Migraines
03/31/2023Pamela WalpoleEmail hidden; Javascript is required.(214) 663-232704/05/202310:45 PM

8/25/1973
Prosper Insurance Company
$ 20 square

  • Back Pain
  • Neck Pain
  • Headaches/Migraines
  • Disc Problems
  • Sciatica
  • Shoulder/Arm Pain
03/29/2023April VarneyEmail hidden; Javascript is required.(469) 222-484705/01/202310:00 AM

4/8/1977
Prosper Blooms
Paid $20 Square
Daughter is having knee surgery next week. She did not want to start and then have to pause. Hence appt being booked for May
In schedule already

  • Back Pain
  • Sinus/Allergies
03/23/2023Tuan NgoEmail hidden; Javascript is required.(214) 621-346104/01/202310:15 AM

3/20/1981
CECPTA Fun Run
Paid d$20 Square

  • Back Pain
03/22/2023Shelby MooreEmail hidden; Javascript is required.(817) 908-451403/30/202310:45 AM

Paid $20 Square
1/3/1997
Sciatica Issues years back

  • Headaches/Migraines
  • Disc Problems
03/22/2023Mike HaganEmail hidden; Javascript is required.(469) 388-433503/30/202309:00 AM

11/19/77
He said he feels like he tore something in his right shoulder. Hurts to even sleep on it. He has an orthopedic appointment tomorrow. I advised him to come in to talk to Doc before making a decision just based on what the ortho potentially says.

  • Back Pain
  • Neck Pain
  • Shoulder/Arm Pain
03/22/2023Daniel KimEmail hidden; Javascript is required.(909) 706-259003/27/202311:00 AM

Artificial c5 & c6. Compressed discs
Similar pain to sciatica
Left rotator cuff pain
$ 20 Square
2/4/86

  • Back Pain
  • Neck Pain
  • Sinus/Allergies
  • Hip/Leg Pain
  • Headaches/Migraines
  • Disc Problems
  • Shoulder/Arm Pain
03/07/2023Phillip BattleEmail hidden; Javascript is required.(614) 589-947303/14/202302:00 PM

5/27/81
Booked over the phone by his daughter who attended the game
Legends Game

  • Back Pain
03/06/2023Jake MyersEmail hidden; Javascript is required.(469) 247-408803/14/202309:30 AM

6/6/95
Wants a consult only
Legends Game

  • Back Pain
03/06/2023Axel FloresEmail hidden; Javascript is required.(214) 870-638903/15/202302:45 PM

4/29/87
Luxe Design Frisco
Confirming / paying via phone on 3/7

  • Back Pain
03/05/2023Brynlee BurrowEmail hidden; Javascript is required.(817) 797-549703/14/202305:00 PM

11/15/2011
Paid $49
Daughter of Brent

  • Back Pain
03/05/2023Blaine BurrowEmail hidden; Javascript is required.(817) 797-549703/14/202304:30 PM

9/29/2015
Paid $49
Son of Brent
Frisco Classic

  • Back Pain
03/05/2023Lisa BurrowEmail hidden; Javascript is required.(817) 797-549703/14/202303:30 PM

9/13/1982
Paid $49
Wife of Brent
Frisco Classic

  • Back Pain
03/05/2023Brent BurrowEmail hidden; Javascript is required.(817) 797-549703/14/202302:30 PM

12/10/1980
Paid $49
Frisco Classic

  • Back Pain
03/05/2023Amy Van VrankenEmail hidden; Javascript is required.(214) 728-144503/10/202310:30 AM

6/20/75
Paid $49 Square
Frisco Classic

  • Neck Pain
  • Sinus/Allergies
  • Ear Aches
  • Shoulder/Arm Pain
03/05/2023Daniel MiltonEmail hidden; Javascript is required.(214) 598-369803/07/202309:00 AM

12/22/1984
Can’t turn neck without pain. Has to turn full body
Paid $49 Square
Frisco Classic

  • Neck Pain
03/03/2023Jason ReevesEmail hidden; Javascript is required.(903) 738-732103/08/202303:00 PM

2/3/79
Torn rotator cuff
Paid $49
Frisco Classic

  • Shoulder/Arm Pain
03/02/2023Houman GhanbarnejadEmail hidden; Javascript is required.(972) 742-880603/06/202309:30 AM

1/14/1998
Paid $20 Square
MN Frisco Thurs AM

  • Back Pain
  • Hip/Leg Pain
03/02/2023Evelyn ZermenoEmail hidden; Javascript is required.(214) 784-130403/22/202309:30 AM

12/29/1991
Paid $20 Square
MN Frisco Thursday AM

  • Back Pain
  • Sinus/Allergies
  • Numbness/Tingling
  • Shoulder/Arm Pain
03/02/2023Loni BurtonEmail hidden; Javascript is required.(903) 337-886103/12/202311:00 AM

2/7/97
Paid $20 Cash
Tender’s worker
MN Frisco Thursday AM

  • Back Pain
  • Hip/Leg Pain
  • Numbness/Tingling
02/26/2023Tyson MaroneyEmail hidden; Javascript is required.(214) 215-948703/03/202308:00 AM

12/15/71
Paid $20 Square
Wife booked for hubby
Call Monday to confirm day and time

  • Back Pain
02/23/2023Louis MantoEmail hidden; Javascript is required.(469) 873-912703/02/202302:00 PM

2/19/98
MN Jersey Showcase

  • Back Pain
  • Sinus/Allergies
  • Hip/Leg Pain
02/23/2023Detlef DomagalskiEmail hidden; Javascript is required.(469) 929-888903/03/202310:00 AM

08/23/82
Jersey’s Showcase

  • Back Pain
02/23/2023Danny CruzEmail hidden; Javascript is required.(469) 207-400003/02/202304:30 PM

Aug 15, 1990
Jersey Showcase

  • Sinus/Allergies
02/23/2023Kristen GilbertEmail hidden; Javascript is required.(469) 396-728002/24/202309:15 AM

9/26/74
MN Jersey Showcase

  • Back Pain
Screening DateNameEmailPhoneAppointment DateAppointment TimeNOTES: (office use only)Recently Experienced Symptoms:

Displaying 1 - 25 of 81