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Screening Survey – Align Chiropractic Clinic Eastside

by | Jun 22, 2022

Displaying 1 - 25 of 188

NameScreening DateEmailPhoneAppointment DateAppointment TimeNOTES: (office use only)Recently Experienced Symptoms:
Aangelyn Mccord07/29/2022Email hidden; Javascript is required.(573) 836-085908/04/202209:00 AM
  • Back Pain
  • Neck Pain
  • Headaches/Migraines
angelyn Mccord07/29/2022Email hidden; Javascript is required.(573) 836-085908/04/202209:00 AM
  • Sinus/Allergies
  • Disc Problems
  • Numbness/Tingling
Erika Salmons08/24/2022Email hidden; Javascript is required.(573) 291-091109/03/202209:00 AM

Johns only

  • Back Pain
  • Neck Pain
  • Headaches/Migraines
IJasmine Rustemeyer08/28/2022Email hidden; Javascript is required.(555) 555-676703/03/202201:00 AM
  • Back Pain
  • Neck Pain
  • Ear Aches
  • Headaches/Migraines
Mikeli Lueckenotte08/28/2022Email hidden; Javascript is required.(573) 690-419605/05/202201:00 AM
  • Back Pain
  • Neck Pain
  • Headaches/Migraines
Madisen Williamson08/28/2022Email hidden; Javascript is required.(573) 508-337509/01/202209:15 AM

West side

  • Back Pain
  • Neck Pain
  • Sinus/Allergies
  • Hip/Leg Pain
  • Disc Problems
  • Numbness/Tingling
Heather Mihalevich08/28/2022Email hidden; Javascript is required.(573) 356-713507/11/202201:00 AM
  • Headaches/Migraines
Mercedes Barnard08/28/2022Email hidden; Javascript is required.(573) 645-305808/30/202205:30 PM

Paid 20 Mercedes

  • Back Pain
  • Neck Pain
  • Sinus/Allergies
  • Hip/Leg Pain
  • Headaches/Migraines
Kaitlyn Hiller08/28/2022Email hidden; Javascript is required.(573) 508-928108/29/202212:00 PM

React

  • Back Pain
  • Neck Pain
  • Sinus/Allergies
  • Ear Aches
  • Headaches/Migraines
  • Numbness/Tingling
  • Shoulder/Arm Pain
Nicole Meller08/28/2022Email hidden; Javascript is required.(573) 291-288205/09/202103:00 AM

Didn’t sign

  • Back Pain
  • Neck Pain
  • Sinus/Allergies
  • Ear Aches
  • Hip/Leg Pain
  • Headaches/Migraines
  • Numbness/Tingling
  • Shoulder/Arm Pain
Adrianna Koty08/28/2022Email hidden; Javascript is required.(815) 641-617505/05/202201:00 AM
  • Sinus/Allergies
  • Ear Aches
  • Headaches/Migraines
  • Shoulder/Arm Pain
Patricio Carranza08/28/2022Email hidden; Javascript is required.(708) 378-109808/29/202203:15 PM

Potentially rib issues

  • Back Pain
  • Shoulder/Arm Pain
Kate Schlichting08/28/2022Email hidden; Javascript is required.(573) 680-830301/01/202204:00 AM
  • Back Pain
Kassidy Schrimpf08/28/2022Email hidden; Javascript is required.(573) 291-383301/01/202201:00 AM
  • Back Pain
  • Neck Pain
  • Headaches/Migraines
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
Ananda Hardy08/28/2022Email hidden; Javascript is required.(573) 418-278301/01/202201:00 AM
  • Back Pain
Tiara Washington08/28/2022Email hidden; Javascript is required.(573) 353-698308/29/202205:30 PM

No complaints
Paid MasterCard

  • Back Pain
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
Nola Polly08/28/2022Email hidden; Javascript is required.(573) 690-513201/01/202201:00 AM

Reach out

  • Sinus/Allergies
  • 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
Adrienne Hafley08/28/2022Email hidden; Javascript is required.(573) 410-565801/01/202101:00 AM
  • Neck Pain
  • Headaches/Migraines
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
Ashley Wittje08/28/2022Email hidden; Javascript is required.(573) 201-064208/08/202103:00 AM

Knee pain left
Didn’t schedule

  • Hip/Leg Pain
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
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
NameScreening DateEmailPhoneAppointment DateAppointment TimeNOTES: (office use only)Recently Experienced Symptoms:

Displaying 1 - 25 of 188