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Screening Survey – Align Chiropractic Clinic Eastside

by | Jun 22, 2022

Displaying 151 - 175 of 188

NameScreening DateEmailPhoneAppointment DateAppointment TimeNOTES: (office use only)Recently Experienced Symptoms:
Hannah Nacy02/25/2023Email hidden; Javascript is required.(816) 585-535603/01/202312:00 PM

#Very nervous but has headaches and was working Jefferson booth
East side

  • Back Pain
  • Neck Pain
  • Headaches/Migraines
Carol Backes02/25/2023Email hidden; Javascript is required.(573) 469-867602/27/202302:45 PM
  • Back Pain
  • Neck Pain
  • Hip/Leg Pain
  • Headaches/Migraines
Geta Dacila02/25/2023Email hidden; Javascript is required.(573) 690-653503/07/202305:20 PM
  • Back Pain
  • Hip/Leg Pain
Misty Brauner02/25/2023Email hidden; Javascript is required.(417) 630-529801/01/198901:00 AM
  • Back Pain
  • Neck Pain
  • Headaches/Migraines
Doug Mantle02/25/2023Email hidden; Javascript is required.(573) 694-499903/01/202305:20 PM

Right shoulder week felt like popped out

  • Shoulder/Arm Pain
Alyssa Buchholz02/25/2023Email hidden; Javascript is required.(573) 826-775701/01/197101:00 AM

Kid with parents

  • Sinus/Allergies
Carol Harris02/25/2023Email hidden; Javascript is required.(573) 338-031501/01/198701:00 AM
  • Hip/Leg Pain
John Mckinzie02/25/2023Email hidden; Javascript is required.(660) 221-600401/01/199601:00 AM
  • Back Pain
  • Neck Pain
  • Sinus/Allergies
  • Hip/Leg Pain
  • Sciatica
Ed Keyser02/24/2023Email hidden; Javascript is required.(573) 338-014701/01/198501:05 AM

Right hand and index and left side of neck, interested but not willing to schedule, took card

  • Back Pain
  • Neck Pain
Shamiya Parks02/24/2023Email hidden; Javascript is required.(573) 619-872101/01/202301:00 AM

Potential not scheduled

  • Back Pain
  • Neck Pain
  • Hip/Leg Pain
  • Headaches/Migraines
  • Numbness/Tingling
  • Sciatica
  • Shoulder/Arm Pain
Elizabeth Robinson02/24/2023Email hidden; Javascript is required.(573) 353-904701/01/202301:00 AM

Potential gave card
DID NOT SCHEDULE

  • Back Pain
  • Neck Pain
  • Sinus/Allergies
  • Sciatica
Rose Bogel02/24/2023Email hidden; Javascript is required.(573) 216-096702/01/202305:00 AM

Hammer toe fixed
Bunions
Structural issues foot
Did not schedule

  • Back Pain
  • Neck Pain
Kelli Johnson09/17/2022Email hidden; Javascript is required.(573) 619-153501/01/202001:00 AM
  • Neck Pain
Elizabeth Radaza08/28/2022Email hidden; Javascript is required.(314) 660-486409/23/202209:00 AM

Calling tomorrow for card

  • Back Pain
  • Sinus/Allergies
  • Hip/Leg Pain
  • Headaches/Migraines
  • Numbness/Tingling
Tina Newton08/28/2022Email hidden; Javascript is required.(573) 694-320808/30/202212:00 PM

Paid card

  • Back Pain
  • Neck Pain
  • Hip/Leg Pain
  • Headaches/Migraines
  • Numbness/Tingling
Ashley Wittje08/28/2022Email hidden; Javascript is required.(573) 201-064208/08/202103:00 AM

Knee pain left
Didn’t schedule

  • Hip/Leg Pain
Rebecca Dirkes08/28/2022Email hidden; Javascript is required.(406) 599-687109/06/202205:30 AM

Right foot numbness
Discover card

  • Sinus/Allergies
  • Hip/Leg Pain
  • Headaches/Migraines
  • Numbness/Tingling
  • Sciatica
Adrienne Hafley08/28/2022Email hidden; Javascript is required.(573) 410-565801/01/202101:00 AM
  • Neck Pain
  • Headaches/Migraines
Rebecca Lewis08/28/2022Email hidden; Javascript is required.(573) 289-524609/01/202212:00 PM

Off and on leg paiIn
Paid cash
Works at Budweiser Clydesdale farm

  • Back Pain
  • Hip/Leg Pain
  • Disc Problems
  • Numbness/Tingling
  • Sciatica
  • Shoulder/Arm Pain
Nola Polly08/28/2022Email hidden; Javascript is required.(573) 690-513201/01/202201:00 AM

Reach out

  • Sinus/Allergies
  • Headaches/Migraines
Travis Huffman08/28/2022Email hidden; Javascript is required.(573) 587-142608/06/202103:00 AM

Spondylosis
Didn’t sign from columbia

  • Back Pain
  • Sinus/Allergies
  • Hip/Leg Pain
Tiara Washington08/28/2022Email hidden; Javascript is required.(573) 353-698308/29/202205:30 PM

No complaints
Paid MasterCard

  • Back Pain
Ananda Hardy08/28/2022Email hidden; Javascript is required.(573) 418-278301/01/202201:00 AM
  • Back Pain
Jackie Buschjost08/28/2022Email hidden; Javascript is required.(573) 694-167508/01/202103:00 AM

Right hand
Would you schedule

  • Neck Pain
  • Sinus/Allergies
  • Numbness/Tingling
Kassidy Schrimpf08/28/2022Email hidden; Javascript is required.(573) 291-383301/01/202201:00 AM
  • Back Pain
  • Neck Pain
  • Headaches/Migraines
NameScreening DateEmailPhoneAppointment DateAppointment TimeNOTES: (office use only)Recently Experienced Symptoms:

Displaying 151 - 175 of 188