Thanks For Scheduling Your Appointment!

Thanks For Scheduling Your Appointment!

In order for us to best prepare for your appointment, please complete this brief survey below within the next 10 minutes:

On a scale of 1-10, one being hardly any pain and ten being unbearable, how would you rate your pain? *

Where is the source of your pain? Choose all options that apply. *

Neck

Back

Knee

Shoulder

Arms

Legs

Headache

Other

What type of doctors have you seen? Choose all options that apply. *

Chiropractor

Pain Management

Neurologist

Orthopaedic Surgeon

General/Family Doctor

Other

None

How did the pain begin? Choose all options that apply. *

Accident at home

Vehicle accident

Accident at work/work related

It just began

After surgery

Came on gradually

Sports related

Other

What areas of your life are affected by the pain? Choose all options that apply. *

Maintaining a safe environment

Communication

Breathing

Eating & drinking

Washing & dressing

Mobilization

Working & playing

Expressing sexuality

Sleeping

Daily parenting

Finances

Household chores

Self worth/value

Physical well-being

Emotional health

Other

How committed are you to fixing your pain?

Very Committed

Somewhat Committed

Neutral

Not ready to commit yet

PLEASE ACKNOWLEDGE THE FOLLOWING STATEMENT: I will NOT miss my appointment because I respect your time and I understand it's not fair to others who would schedule in my place if I don't show up. *

Yes

PLEASE ACKNOWLEDGE THE FOLLOWING STATEMENT: I understand that the office is located at 3106 Devine Street, Columbia 29205. *

Yes

First Name *

Last Name *

Email *

Phone *

Midlands Health Center

3106 Devine Street, Columbia 29205 | (803) 252-2255