Health Survey

If you are interested in a personal contact from a Doctor of Chiropractic or in receiving new patient information, please complete the form below. To assist the doctor we kindly ask that you be as thorough as possible. For a free consultation, please call DR. TOM at: (619) 298-BACK (2225). Thank you.

Name    Age 
City     State   Zip 
Phone    Work           Male Female

Please mark any of the following that apply to you.

Is your condition related to an automobile accident?
Is your condition related to an accident that occurred at work?
Has the pain changed your quality of life?

Headaches     Neck Pain        Low Back Pain Joint Pain
Fatigue       Nervousness      Dizziness     Pain Between Shoulder Blades
Weakness      Numbness         Tingling      Tension Across Top of Shoulders
Irritability  Trouble Sleeping Allergies     Digestive Problems

Which of the above bothers you the most?
How long have you been bothered by this condition?
Please include any additional comments or information regarding your condition here.

CHIROPRACTIC CAN HELP YOU because Chiropractic Doctors gently treat the body, naturally, without drugs to remove the stress and imbalances that CAUSE health problems.

Would you like to get rid of your health problem? Yes No

If your answer is Yes, there are a couple alternatives available to you.

I would like to come to the Doctor's office for a complete evaluation. There is NO CHARGE for this examination. This will allow me to find out if I can be helped by Chiropractic without any financial barriers.

I would like the Doctor to call me to discuss my health problems before making an appointment.


To submit your information, press the Send button:


If the form does not work for you you may send the information via e-mail to Dr. Tom at or call (619)296-BACK(2225) for additional information.

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