Please check off any symptoms that apply to you to assess your spinal health:
| PAIN | LOSS OF FUNCTION |
| □ Neck Pain/Stiffness | □ Frequent Colds/Flu |
| □ Headaches/Migraine | □ Asthma |
| □ Pain between Shoulders | □ Sinus/Allergies |
| □ Pain/Numbness in Arms or Hands | □ Fatigue |
| □ Pain/Numbness in Legs or Feet | □ Ear Infection/Tonsillitis |
| □ Low Back Pain | □ Dizzy/Light-Headed |
| □ Car Accident | □ Difficulty Sleeping |
| □ Serious Fall or Injury | □ Nervousness/Depression |
| □ Arthritis or Swollen Joints | □ Poor Concentration/Memory |
| □ Spinal Curvature (Scoliosis) | □ Muscle Weakness |
| □ Walking Problems | □ Digestive Problems |
| □ Sports Injuries | □ ADD/ADHD |
If you’ve checked off any of these symptoms, there is a possibility that you have spinal subluxations (misalignments). If left unchecked these health issues can worsen over time and cause permanent damage.
Subluxations can be caused by:
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Regular visits to your chiropractor can help reduce the effects of subluxations and restore health back into your body. To check if your health problems are caused by subluxations, give us a call at 519-653-1020.
If you print off this survey with your results and bring it with you to your First Appt, you will receive your Initial Visit with us (Consultation, Physical Examination and X-rays – if necessary) for only $39.00 (Normal Fee $170.00)! This is valid only until August 28, 2014.
