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Which one best describes you?

I have had chronic pain for a long time

I have a new injury

I feel great, I just need a checkup

Have you ever had any of the following? (choose multiple)

Low back tension or pain

Frequent headaches that start at the base of the skull

Pinching pain in the mid back

A sharp or shooting pain along the spine

TMJ dysfunction (popping, clicking or pain in the jaw)

Have you ever been diagnosed with? (choose multiple)

Spinal arthritis

Bulging disc

Degenerated discs

Whiplash

Concussion

Have you ever noticed? (choose multiple)

One of your shoulders is higher than the other

Your head juts forward and your ear is no longer above your shoulder

You can’t turn your head all the way without pain

You can’t get comfortable on your pillow at night

You feel like you want to pop your spine for relief

Have you ever? (choose multiple)

Been in an auto accident

Had a sports injury

Perform repetitive motions for your job (like sitting or typing)

“Pulled” your low back or neck

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