Over the last 12 months have you been involved in:

Auto Injury
Work Injury
Sports Injury
Other Injury

If "Other Injury", please explain:

Check any of the following symptoms that apply to you:

Back or Neck Pain, Stiffness, Soreness
Headaches
Pain between the Shoulder Blades
Muscular Spasms and Tightness
Pain, Numbness or Tingling in Extremities
Chronic Pain
Painful Joints
Excess Stress
Dizziness or Loss of Balance
Low Energy and Sluggishness

How has your health condition impacted your life? i.e. prevented you from doing?

What health goals have you set for yourself?

To initiate or improve upon a fitness program          To lose excess weight                        
To build extra muscle                                  To consume a healthier diet                  
To participate in a preventive health plan             other                                          

If other please explain:

Questions you would like to ask the Doctors....

If you would like us to contact you OR send you an information packet, please give  some information about yourself:

First Name
Last Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Work Phone
Home Phone
E-mail

How should we contact you?

Home telephone
Work telephone
E-mail

How would you rate our site?

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Very useful
Slightly useful
Not useful 

Additional Comments