Online Forms to fill out

Oswestry Low Back

Downloadable forms

Member ID

Insurance ID

In past week, how often have your symptoms been present

Please select the percentage below

Current Pain level from 1 to 10

On a scale of 0 to 10, 0 being no pain to 10 being unbearable

What is your average pain over the past week

On a scale of 0 to 10, 0 being no pain to 10 being unbearable

What is your worst pain over the past week

On a scale of 0 to 10, 0 being no pain to 10 being unbearable

How much has your pain interference with your daily activities?

On a scale of 0 to 10, 0 being no interference to 10 being unable to carry on any activities

What are your goals for acupuncture treatment?

Briefly described below

How do you track your progress towards your goals?

Briefly described below

What progress has been made towards your goals

Briefly described below

Current Complaints #1

Current Complaints #2

Current Complaints #3

Rate your overall progress since starting acupuncture

Please select your overall progress for complaint #1

Rate your overall progress since starting acupuncture for complaint 2

Please select your overall progress for complaint #2

Rate your overall progress since starting acupuncture or complaint 3

Please select your overall progress for complaint #3

What type of treatments have been helpful for your conditions?

Acupuncture Treatment

Chinese Herbs

Nutritional Supplement

Prescription Medication

Spinal Ajustment/Manipulation

Physical Therapy

Manual Therapy (Graston)

Deep Muscle Stimulator

Any new complaints or conditions?

If Yes please describe below otherwise skip

Have you had any re-injuries or events that have prolonged your recovery?

If Yes please describe below, otherwise skip

Are you pregnant?

If yes please briefly type in how many weeks and if you are under a physicians care

Learn more

Oswestry Low Back Form
Description text goes here
Description text goes here

Online Forms to fill out

Downloadable forms

Chiropractic & Acupuncture Wellness Center

Info

Forms

Call 760-650-2247
for a free consultation

Online Forms to fill out

Downloadable forms

test1

Accordion Item 2

Accordion Item 3