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.

If you are human, leave this field blank.

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?

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Chiropractic Hand & Foot Clinics of America

Email: info@handandfootclinics.com

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