By filling out this survey, you can help us to learn more about the general condition of our visitors. All information submitted remains confidential and is only used to enhance the services we offer and better serve you.

Check any of the following symptoms you have experienced in the past 6 months.

Headaches/Tension
Fatigue, Tired
Pain Anywhere in Body
Digestive Disturbance
Difficulty Sleeping
Irritability
Low Back Pain
Neck Pain
Wrist/Hand Pain
Elbow Pain
Shoulder Pain
Hip Pain

Pain Between Shoulder Blades
Knee Pain
Ankle/Foot Pain
Ringing in Ears
Nervous
Dizziness
Allergies
Tension Across Top of Shoulders
Numbing/Tingling in Arms or Hands
Numbing/Tingling in Legs or Feet
Weight Trouble
Other

Which of the above bothers you the most?



How long have you been bothered by this condition?

Less than a month 1 to 3 months 4 to 12 months
2 years 2+ years

Does this cause you to be:

Moody
Irritable
Interrupts Sleep
Restricted on Daily Activities

Does this affect your work:

Decision Making
Poor Attitude
Decreased Productivity
Exhausted at End of Day
Unable to Work Long Hours

Does this affect your life:

Lose Patience with Spouse or Children
Restricted Household Duties
Hinders Ability to Exercise or Participate in Sports
Interferes with Ability to Participate in Hobbies or
Other Desired Activities

Would you like to get rid of the problem?
Yes No
I would like to come to the Doctor's office for an initial consultation. There is NO CHARGE for this consultation. This will allow me to find out if I can be helped by Chiropractic without any financial barriers.
         Yes No

I would like to come to a class on Stress and Wellness.

Yes No

I would like a staff member from Doctor Houk's office to call me
before making an appointment.

          I am a member of an HMO or Health Care Network.

Name of HMO

By filling out the E-mail Section below you will receive notification of PRODUCT & SERVICES SPECIALS, COUPONS, and other special PROMOTIONS that are offered quarterly.

Items marked with a * are only necessary if you are requesting DR Houk to contact you.

Items marked with a * assist us with demographic information.
We appreciate your assistance!

*Name *
*Age *
*City *
*State/Province *
*Zip/Post Code *
*Phone *
*E-mail *
*Occupation *

 

 

©2002 Doctor Houk
Problems with this webpage? Please contact the webmaster.