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Screening Survey – Align Chiropractic Clinic Eastside

by | Jun 22, 2022

Displaying 126 - 150 of 188

NameScreening DateEmailPhoneAppointment DateAppointment TimeNOTES: (office use only)Recently Experienced Symptoms:
Linda Turner03/28/2023Email hidden; Javascript is required.(573) 415-640904/03/202305:20 PM
  • Back Pain
  • Sinus/Allergies
  • Hip/Leg Pain
  • Shoulder/Arm Pain
Jason Ollison03/23/2023Email hidden; Javascript is required.(573) 680-280203/29/202309:15 AM
  • Back Pain
  • Neck Pain
  • Sinus/Allergies
  • Hip/Leg Pain
  • Headaches/Migraines
  • Numbness/Tingling
  • Shoulder/Arm Pain
Hailey Dudenhoeffer03/23/2023Email hidden; Javascript is required.(573) 694-187903/10/202309:15 AM

Torn rotator cuff rt

  • Back Pain
  • Hip/Leg Pain
  • Headaches/Migraines
  • Shoulder/Arm Pain
Ashton Stalling03/23/2023Email hidden; Javascript is required.(423) 987-496503/01/202201:00 AM

Previous issues with sinuses associated
Headaches and neck

  • Back Pain
  • Neck Pain
  • Sinus/Allergies
  • Ear Aches
  • Hip/Leg Pain
  • Headaches/Migraines
Maris Ollison03/23/2023Email hidden; Javascript is required.(660) 221-124104/04/202312:00 PM

Dislocated left shoulder with a partially torn labrum

  • Back Pain
  • Hip/Leg Pain
  • Numbness/Tingling
  • Shoulder/Arm Pain
Audrey Rowe03/23/2023Email hidden; Javascript is required.(817) 807-178903/01/202301:00 AM

Already patient

  • Back Pain
  • Neck Pain
  • Sinus/Allergies
  • Numbness/Tingling
  • Shoulder/Arm Pain
Jackie Marquez03/23/2023Email hidden; Javascript is required.(219) 718-260003/01/202301:00 AM

Mid back pain right sided muscle spasms
Occasional neck pain
Did not sign

  • Back Pain
  • Neck Pain
  • Sinus/Allergies
Emily Williams03/23/2023Email hidden; Javascript is required.(417) 231-332103/29/202309:00 AM

Previous low back pain

  • Back Pain
  • Disc Problems
Joscelynn Marriott03/23/2023Email hidden; Javascript is required.(573) 832-831103/01/202201:00 AM

Pitcher,running home ball hit forearm
Didn’t make an appt

  • Back Pain
  • Sinus/Allergies
  • Ear Aches
  • Hip/Leg Pain
  • Numbness/Tingling
  • Shoulder/Arm Pain
Katie Blair03/22/2023Email hidden; Javascript is required.(520) 471-544703/28/202309:15 AM
  • Back Pain
  • Numbness/Tingling
  • Shoulder/Arm Pain
Dummy Test03/22/2023Email hidden; Javascript is required.(777) 777-777701/01/202301:00 AM
  • Back Pain
  • Headaches/Migraines
Dummy Test03/20/2023Email hidden; Javascript is required.(666) 666-666601/01/202301:00 AM
  • Back Pain
Hb Doddes03/21/2023Email hidden; Javascript is required.(507) 420-655701/01/202301:00 AM

Left elbow
Didn’t schedule

  • Shoulder/Arm Pain
Christina Laughlin03/21/2023Email hidden; Javascript is required.(573) 694-484803/29/202302:45 PM

Spinal stenosis

  • Back Pain
Kim Verslues03/21/2023Email hidden; Javascript is required.(573) 694-548803/27/202305:20 PM

Vein care
Pt for hold rat leg
Shots

  • Back Pain
  • Neck Pain
  • Sinus/Allergies
  • Hip/Leg Pain
  • Numbness/Tingling
  • Sciatica
  • Shoulder/Arm Pain
Fredrick Hill03/15/2023Email hidden; Javascript is required.(573) 338-208703/29/202305:20 PM
  • Back Pain
  • Neck Pain
  • Headaches/Migraines
Levi Mansell03/14/2023Email hidden; Javascript is required.(573) 430-824103/23/202302:45 PM

8 months ago car accident

  • Back Pain
  • Neck Pain
  • Hip/Leg Pain
  • Numbness/Tingling
  • Sciatica
  • Shoulder/Arm Pain
Cassandra Crane03/14/2023Email hidden; Javascript is required.(573) 366-109103/23/202305:20 PM
  • Sinus/Allergies
  • Headaches/Migraines
  • Numbness/Tingling
  • Shoulder/Arm Pain
Heather Weed03/14/2023Email hidden; Javascript is required.(573) 291-049503/22/202303:00 PM

Arthritis in the neck

  • Back Pain
  • Neck Pain
  • Hip/Leg Pain
  • Headaches/Migraines
  • Numbness/Tingling
  • Sciatica
Cindy Patterson03/14/2023Email hidden; Javascript is required.(573) 480-209204/06/202305:20 AM
  • Back Pain
  • Neck Pain
  • Hip/Leg Pain
  • Numbness/Tingling
  • Sciatica
Jeni Mcginnis03/14/2023Email hidden; Javascript is required.(573) 353-207704/06/202305:20 PM

High blood pressure

  • Back Pain
  • Neck Pain
  • Headaches/Migraines
  • Numbness/Tingling
  • Sciatica
Debbie Wallace03/14/2023Email hidden; Javascript is required.(573) 295-419203/20/202312:00 AM

Hands and feet

  • Back Pain
  • Neck Pain
  • Numbness/Tingling
Haley Richardson03/13/2023Email hidden; Javascript is required.(573) 645-688303/22/202303:30 PM

Shoulder reduction

  • Back Pain
  • Neck Pain
  • Hip/Leg Pain
  • Headaches/Migraines
  • Shoulder/Arm Pain
Alyshia Moody02/25/2023Email hidden; Javascript is required.(207) 816-023803/02/202312:00 PM

Slipped down stairs and has had pain since
Paid cash wants to come in early to fill out paperwork

  • Back Pain
  • Sinus/Allergies
  • Headaches/Migraines
  • Numbness/Tingling
Scott Peterson02/25/2023Email hidden; Javascript is required.(636) 359-390601/01/202301:00 AM

Didn’t sign but was interested

  • Back Pain
  • Neck Pain
  • Headaches/Migraines
  • Shoulder/Arm Pain
NameScreening DateEmailPhoneAppointment DateAppointment TimeNOTES: (office use only)Recently Experienced Symptoms:

Displaying 126 - 150 of 188