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Surveys

Labelle Chiropractic Clinic Intake Survey

This is a short survey which may indicate whether Chiropractic treatment may be of assistance to you. If you answer YES to one of more questions, you may be a candidate for a chiropractic subluxation check-up.

Have you ever been in an auto accident or taken a bad fall?

 Yes    No  

Do you have neck or back pain more than 2 times monthly?

 Yes    No  

Do you feel fatigued late in the day?

 Yes    No  

Do you have chronic digestive problems?

 Yes    No  

Do you suffer from headaches or migraines more then 2 times per month?

 Yes    No  

Do you have frequent pain for an unknown cause, such as sciatica?

 Yes    No  

Do your hands or feet tingle, ache, burn or feel numb at any time?

 Yes    No  

Do you suffer from allergies, asthma or other breathing problems?

 Yes    No  

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This survey was prepared by Logicbank Media.