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Screening Survey – Align Chiropractic Clinic Eastside

by | Jun 22, 2022

Displaying 51 - 75 of 188

NameScreening DateEmailPhoneAppointment DateAppointment TimeNOTES: (office use only)Recently Experienced Symptoms:
Hb Doddes03/21/2023rpe11056@yahoo.com(507) 420-655701/01/202301:00 AM

Left elbow
Didn’t schedule

  • Shoulder/Arm Pain
Dummy Test03/20/2023uccdyrxjfchgvhgc@gmail.com(666) 666-666601/01/202301:00 AM
  • Back Pain
Dummy Test03/22/2023h@gmail.com(777) 777-777701/01/202301:00 AM
  • Back Pain
  • Headaches/Migraines
Katie Blair03/22/2023kaitlynjblair@gmail.com(520) 471-544703/28/202309:15 AM
  • Back Pain
  • Numbness/Tingling
  • Shoulder/Arm Pain
Joscelynn Marriott03/23/2023marriottjoss18@gmail.com(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
Emily Williams03/23/2023emilymichelle0701.ew@gmail.com(417) 231-332103/29/202309:00 AM

Previous low back pain

  • Back Pain
  • Disc Problems
Jackie Marquez03/23/2023jacquelinemarquez2020@gmail.com(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
Audrey Rowe03/23/2023arwe158@gmail.com(817) 807-178903/01/202301:00 AM

Already patient

  • Back Pain
  • Neck Pain
  • Sinus/Allergies
  • Numbness/Tingling
  • Shoulder/Arm Pain
Maris Ollison03/23/2023marisollison8@gmail.com(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
Ashton Stalling03/23/2023avstalling01@gmail.com(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
Hailey Dudenhoeffer03/23/2023haileydudenhoeffer@gmail.com(573) 694-187903/10/202309:15 AM

Torn rotator cuff rt

  • Back Pain
  • Hip/Leg Pain
  • Headaches/Migraines
  • Shoulder/Arm Pain
Jason Ollison03/23/2023ollisonj@lincolnu.edu(573) 680-280203/29/202309:15 AM
  • Back Pain
  • Neck Pain
  • Sinus/Allergies
  • Hip/Leg Pain
  • Headaches/Migraines
  • Numbness/Tingling
  • Shoulder/Arm Pain
Linda Turner03/28/2023linblt123@gmail.com(573) 415-640904/03/202305:20 PM
  • Back Pain
  • Sinus/Allergies
  • Hip/Leg Pain
  • Shoulder/Arm Pain
Lynn Page03/28/2023lynnpage1975@gmail.com(573) 353-204301/01/202301:00 AM

Didn’t schedule

  • Back Pain
  • Neck Pain
  • Sinus/Allergies
  • Hip/Leg Pain
  • Headaches/Migraines
  • Shoulder/Arm Pain
Ashley Davis03/28/2023ashdavisa@gmail.com(573) 418-886101/01/202301:00 AM

Didn’t schedule

  • Hip/Leg Pain
  • Headaches/Migraines
  • Numbness/Tingling
  • Shoulder/Arm Pain
Travis Feltrop03/28/2023tjfeltrop@gmail.com(573) 616-910304/05/202309:00 AM
  • Back Pain
  • Hip/Leg Pain
  • Sciatica
  • Shoulder/Arm Pain
Nikki Hazelton04/10/2023nikkiandt315@gmail.com(573) 619-371501/01/202301:00 AM
  • Back Pain
Erin Sutton04/14/2023e.sutton76@gmail.com(402) 575-147704/18/202305:20 PM

Carpal tunnel surgery
Numbness down the are to the last three fingers
Superior hip
Heel spurs and planterfacious

  • Back Pain
  • Neck Pain
  • Sinus/Allergies
  • Hip/Leg Pain
  • Headaches/Migraines
  • Numbness/Tingling
  • Sciatica
  • Shoulder/Arm Pain
Rhonda Rackers04/20/2023kathaleenrrackers1966@gmail.com(573) 864-969701/01/202302:30 PM

Open heart surgery pace maker
Call later

  • Back Pain
  • Sinus/Allergies
  • Hip/Leg Pain
  • Headaches/Migraines
Sherry Kempf04/20/2023alignchiroclinic@gmail.com(573) 690-877901/01/202302:30 AM

Epilepsy
She is a react

  • Back Pain
  • Hip/Leg Pain
  • Sciatica
Amber Pitts04/20/2023lilymarie51014@gmail.com(573) 298-386304/24/202309:15 AM
  • Back Pain
  • Headaches/Migraines
Adam Dunn04/27/2023adamdunn10393@outlook.com(573) 690-363505/03/202303:30 PM
  • Back Pain
Mike Broker04/27/2023michaeljbroker@yahoo.com(573) 469-858005/04/202312:00 AM

Middle back spasm gallbladder removed

  • Back Pain
  • Neck Pain
  • Sinus/Allergies
Myong Hamilton04/28/2023mhh000ir@yahoo.com(573) 528-574703/04/201101:00 AM

Call for follow up

  • Back Pain
Dorothy Rieke04/28/2023rekied1@yahoo.com(573) 859-384501/01/202301:00 AM

Foot surgery
Carpool tunnel
Call and follow up

  • Back Pain
  • Neck Pain
  • Sinus/Allergies
  • Hip/Leg Pain
  • Disc Problems
  • Numbness/Tingling
  • Shoulder/Arm Pain
NameScreening DateEmailPhoneAppointment DateAppointment TimeNOTES: (office use only)Recently Experienced Symptoms:

Displaying 51 - 75 of 188