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Screening Survey – The Chiro Place – Collierville

by | Jun 16, 2022

Displaying 1 - 25 of 57

Screening DateNameEmailPhoneAppointment DateAppointment TimeNOTES: (office use only)Recently Experienced Symptoms:
04/18/2023Martha WebbEmail hidden; Javascript is required.(901) 487-063704/25/202303:30 PM

AS

  • Numbness/Tingling
03/28/2023Nakia HolmesEmail hidden; Javascript is required.(901) 643-987704/01/202309:30 AM
  • Back Pain
  • Neck Pain
  • Headaches/Migraines
  • Numbness/Tingling
03/27/2023Marjorie JamersonEmail hidden; Javascript is required.(901) 430-400803/27/202303:30 PM

A.S.
KIPP HEALTH FAIR
PAID SQUARE

  • Back Pain
  • Neck Pain
  • Sinus/Allergies
  • Ear Aches
  • Hip/Leg Pain
  • Headaches/Migraines
  • Shoulder/Arm Pain
03/25/2023Olivia HolmesEmail hidden; Javascript is required.(901) 691-066404/03/202303:30 PM

A.S.
KIPP HEALTH FAIR
PAID SQUARE

  • Sinus/Allergies
  • Ear Aches
  • Hip/Leg Pain
03/24/2023Terry BranscombEmail hidden; Javascript is required.(901) 218-184503/28/202308:30 AM

Paid via square MC
Dedicated senior center screening 3/24

  • Back Pain
  • Neck Pain
  • Hip/Leg Pain
  • Headaches/Migraines
  • Numbness/Tingling
  • Shoulder/Arm Pain
02/23/2023Regina HoustonEmail hidden; Javascript is required.(501) 772-647903/16/202308:30 AM

C.D.
Senior Health Expo
PAID -SQUARE

  • Neck Pain
  • Sinus/Allergies
  • Headaches/Migraines
  • Shoulder/Arm Pain
01/25/2023Dinisha TimmonsEmail hidden; Javascript is required.(901) 690-858902/04/202310:30 AM

Granville screening
Paid via square 1/25/23

  • Back Pain
  • Neck Pain
  • Sinus/Allergies
  • Ear Aches
  • Shoulder/Arm Pain
01/25/2023Rachel TownsendEmail hidden; Javascript is required.(901) 647-558901/28/202310:30 AM

Granville screening
Paid via Cashapp 1/25/23

  • Sinus/Allergies
01/18/2023Courtney HarrisEmail hidden; Javascript is required.(901) 240-564601/28/202311:00 AM

MBA event 1.18 paid via cashapp HS

  • Sinus/Allergies
  • Hip/Leg Pain
  • Shoulder/Arm Pain
01/18/2023Annie CollierEmail hidden; Javascript is required.(314) 532-363301/24/202306:00 PM

Germantown Elem.
1/18/23
C.D.
PAID

  • Back Pain
  • Neck Pain
  • Sinus/Allergies
  • Numbness/Tingling
01/14/2023LeVelle SalterEmail hidden; Javascript is required.(901) 848-275901/18/202309:00 AM

01/14/2023
Vision Party
Cymphony
PAID: PayPal

  • Sinus/Allergies
  • Hip/Leg Pain
12/15/2022Jenice HillEmail hidden; Javascript is required.(901) 896-948401/14/202308:30 AM

Esporta event 12.15 paid via cashapp HS 12.15

  • Back Pain
  • Neck Pain
  • Numbness/Tingling
12/15/2022Lawrence BellEmail hidden; Javascript is required.(901) 605-206012/19/202211:00 AM

Esporta event 12.15 paid via cashapp HS 12.15

  • Back Pain
12/10/2022Tameka MayEmail hidden; Javascript is required.(601) 310-193512/12/202204:00 PM

Annual fall bazaar event
Paid via PayPal mc 12/10

  • Back Pain
  • Neck Pain
  • Sinus/Allergies
  • Ear Aches
  • Hip/Leg Pain
  • Headaches/Migraines
  • Disc Problems
  • Numbness/Tingling
  • Shoulder/Arm Pain
11/18/2022Lewis GentryEmail hidden; Javascript is required.(901) 246-799911/22/202211:00 AM

Durham m.c.

  • Sinus/Allergies
11/18/2022Wanakee BaynesEmail hidden; Javascript is required.(901) 513-021511/28/202211:30 AM

Durham M.C.

  • Back Pain
  • Neck Pain
  • Hip/Leg Pain
  • Headaches/Migraines
  • Shoulder/Arm Pain
11/18/2022Rhonda CampbellEmail hidden; Javascript is required.(901) 364-283111/28/202209:00 AM

DURHAM M.C.

  • Sinus/Allergies
  • Numbness/Tingling
11/16/2022ChaQueitta JacksonEmail hidden; Javascript is required.(662) 822-917412/10/202209:00 AM
  • Back Pain
  • Neck Pain
  • Sinus/Allergies
  • Hip/Leg Pain
  • Numbness/Tingling
11/08/2022Deidre MathisEmail hidden; Javascript is required.(414) 841-358211/16/202210:30 AM
  • Back Pain
  • Headaches/Migraines
  • Sciatica
11/08/2022Robert WimbleyEmail hidden; Javascript is required.(901) 237-510411/21/202210:30 AM

Hickory Ridge Elm
Paid 30 via cashapp

  • Back Pain
  • Neck Pain
  • Sinus/Allergies
11/08/2022Sharon PageEmail hidden; Javascript is required.(991) 800-669111/10/202204:00 PM

Pervious patient last visit 2019
Paid via cash app bw 11/8

  • Back Pain
  • Hip/Leg Pain
  • Numbness/Tingling
  • Sciatica
11/08/2022Will ChristianEmail hidden; Javascript is required.(973) 885-396611/19/202208:30 AM

Paid via PayPal bw 11/8

  • Back Pain
  • Neck Pain
11/08/2022Ashley MimsEmail hidden; Javascript is required.(901) 643-229111/12/202210:30 AM

Will pay at appt bw 11/8

  • Back Pain
  • Neck Pain
  • Sinus/Allergies
  • Ear Aches
  • Hip/Leg Pain
  • Numbness/Tingling
  • Sciatica
  • Shoulder/Arm Pain
11/08/2022Jc ReedEmail hidden; Javascript is required.(901) 422-359011/19/202209:00 AM
  • Sciatica
11/08/2022Curtis JonesEmail hidden; Javascript is required.(901) 406-973711/19/202211:00 AM

Paid cash at smith and nephew event bw 11/8

  • Sinus/Allergies
Screening DateNameEmailPhoneAppointment DateAppointment TimeNOTES: (office use only)Recently Experienced Symptoms:

Displaying 1 - 25 of 57