Brief Health Questionnaire — Chiropractic Hand & Foot Clinic

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Brief Health Questionnaire

We will use this information to locate a hand and foot chiropractor near you.

First Name *

Last Name *

Email *

City *

State *

Zip Code *

What body regions are you seeking a chiropractor for? *

Hand

Elbow

Shoulder

Arm

Foot

Knee

Hip

Neck

Back

Headaches

Other

Please list your symptoms: *

Have you been diagnosed by another doctor regarding your condition? *

If yes what type of doctor did you see? (if none leave blank)

MD

DO

Podiatrist

Orthopedic specialist

Other

If you have been diagnosed by another doctor what was that diagnosis?

If you are human, leave this field blank.

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Chiropractic Hand & Foot Clinics of America

Email: info@handandfootclinics.com

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