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Screening Survey – Rock Solid Chiropractic Marion

by | May 12, 2022

Displaying 1 - 25 of 30

Screening DateNameEmailPhoneAppointment DateAppointment TimeNOTES: (office use only)Recently Experienced Symptoms:
06/01/2023Derek JustEmail hidden; Javascript is required.(701) 269-185206/09/202309:00 AM

10 yrs ago car accident broke neck

  • Back Pain
  • Disc Problems
06/01/2023Wayne KuslerEmail hidden; Javascript is required.(701) 321-167206/06/202304:00 PM
  • Back Pain
06/01/2023Chad GriffithEmail hidden; Javascript is required.(720) 477-868706/05/202311:35 AM
  • Back Pain
  • Neck Pain
  • Hip/Leg Pain
05/30/2023Sean LangeEmail hidden; Javascript is required.(701) 541-563505/31/202312:00 PM

t boned a deer a year ago/ flipped over the front of his motorcycle

been since 2015 since he has went to a chiropractor

bad hip

over compensates one leg over the other to walk everyday

  • Back Pain
  • Neck Pain
  • Hip/Leg Pain
05/30/2023Victor BethanyEmail hidden; Javascript is required.(701) 320-634305/31/202311:15 AM
  • Neck Pain
  • Headaches/Migraines
05/30/2023Angel GonzalezEmail hidden; Javascript is required.(701) 269-800505/31/202309:00 AM

severe degenerative L4 L5

pinch nerves / tingling numbness in fingers and hands

  • Back Pain
  • Neck Pain
  • Disc Problems
  • Numbness/Tingling
05/18/2023Judi TanataEmail hidden; Javascript is required.(701) 320-118005/24/202305:15 PM

leg pain
migraines
numbness in right arm tingles all the time

started after acupuncture was done/ just flared up this week

month ago chiro/ looking for something new

  • Back Pain
  • Neck Pain
  • Sinus/Allergies
  • Hip/Leg Pain
  • Headaches/Migraines
  • Numbness/Tingling
  • Sciatica
  • Shoulder/Arm Pain
05/17/2023Jan RathEmail hidden; Javascript is required.(701) 952-751106/14/202304:30 PM

back surgery
rotator cuffs on both

  • Back Pain
  • Shoulder/Arm Pain
05/17/2023Nicole LemieuxEmail hidden; Javascript is required.(701) 320-152205/22/202302:00 PM

Left hip alot of problems
Neck is out of place gets headaches migraines

  • Back Pain
  • Neck Pain
  • Sinus/Allergies
  • Hip/Leg Pain
  • Headaches/Migraines
05/17/2023Gina JonesEmail hidden; Javascript is required.(701) 320-822805/19/202312:00 PM

compressed vertebre
fallen back in nov vertigo
xray week ago
sinus allergies worse than ever
pt regiment
numbness in back sometimes
torn rotator cuff/ needs shoulder replacement

  • Back Pain
  • Neck Pain
  • Sinus/Allergies
  • Hip/Leg Pain
  • Headaches/Migraines
  • Numbness/Tingling
  • Shoulder/Arm Pain
05/11/2023Eric JohnsonEmail hidden; Javascript is required.(701) 789-974105/17/202309:00 AM

numbness in his fingers

  • Back Pain
  • Neck Pain
  • Hip/Leg Pain
  • Numbness/Tingling
05/11/2023Lloyd JamesEmail hidden; Javascript is required.(701) 659-183005/17/202302:00 PM

Had a neck fusion / 3 vertebra replaced

sciatica started bothering him a couple months ago

fingers tingle and go numb quite a bit

  • Back Pain
  • Neck Pain
  • Numbness/Tingling
  • Sciatica
  • Shoulder/Arm Pain
05/10/2023Colleen SchmokerEmail hidden; Javascript is required.(701) 320-304105/17/202303:45 PM
  • Shoulder/Arm Pain
03/09/2023Courtney EricksonEmail hidden; Javascript is required.(701) 484-819903/23/202302:00 PM
  • Back Pain
  • Neck Pain
  • Sinus/Allergies
  • Hip/Leg Pain
  • Headaches/Migraines
  • Disc Problems
  • Numbness/Tingling
  • Sciatica
  • Shoulder/Arm Pain
10/04/2022Denise AmannEmail hidden; Javascript is required.(701) 490-051810/11/202209:55 AM

shoulder recent;y injured

  • Numbness/Tingling
  • Shoulder/Arm Pain
10/04/2022Chris HjelleEmail hidden; Javascript is required.(701) 269-653211/02/202203:30 PM
  • Back Pain
  • Neck Pain
  • Hip/Leg Pain
  • Disc Problems
  • Numbness/Tingling
  • Shoulder/Arm Pain
10/04/2022Megan WittenbergEmail hidden; Javascript is required.(701) 652-588811/02/202209:00 AM
  • Back Pain
  • Neck Pain
  • Sinus/Allergies
  • Ear Aches
  • Hip/Leg Pain
  • Headaches/Migraines
10/04/2022Amy OlsenEmail hidden; Javascript is required.(701) 490-275410/18/202203:30 PM

was recently seen and she was told something was going on with L5 disc

  • Back Pain
  • Sinus/Allergies
  • Headaches/Migraines
  • Disc Problems
09/30/2022Christine HattonEmail hidden; Javascript is required.(701) 883-546210/03/202201:15 PM

2 back surgeries : helped a little bit but now constant pain
Numbness in fingers

  • Back Pain
  • Sinus/Allergies
  • Hip/Leg Pain
  • Disc Problems
  • Numbness/Tingling
07/30/2022Caroline ElsnerEmail hidden; Javascript is required.(701) 269-554808/17/202209:15 AM
  • Back Pain
  • Neck Pain
  • Hip/Leg Pain
  • Headaches/Migraines
  • Shoulder/Arm Pain
07/30/2022Samantha LeeEmail hidden; Javascript is required.(701) 680-559808/15/202210:15 AM
  • Back Pain
  • Neck Pain
  • Sinus/Allergies
  • Hip/Leg Pain
  • Headaches/Migraines
  • Numbness/Tingling
  • Sciatica
07/16/2022Julie JansenEmail hidden; Javascript is required.(701) 269-578807/27/202203:45 PM
  • Back Pain
  • Neck Pain
  • Sinus/Allergies
  • Headaches/Migraines
  • Disc Problems
06/14/2022Martin VegaEmail hidden; Javascript is required.(208) 316-107607/08/202209:00 AM
  • Back Pain
  • Sinus/Allergies
  • Headaches/Migraines
  • Numbness/Tingling
06/14/2022Cody JohnsonEmail hidden; Javascript is required.(701) 320-475306/16/202204:00 AM

tension on shoulders

  • Neck Pain
  • Sinus/Allergies
  • Hip/Leg Pain
  • Headaches/Migraines
  • Shoulder/Arm Pain
06/14/2022Mike schwartzEmail hidden; Javascript is required.(701) 320-574406/20/202210:30 AM

tingling above right hip
rotator cuff kind of shot
pain between c1 and c5 on right hand side gets irritated more than anything
had stroke 2 years ago and had to learn to walk again

  • Back Pain
  • Neck Pain
  • Sinus/Allergies
  • Hip/Leg Pain
  • Numbness/Tingling
Screening DateNameEmailPhoneAppointment DateAppointment TimeNOTES: (office use only)Recently Experienced Symptoms:

Displaying 1 - 25 of 30