Well-Balanced Chiropractic Wellness Center Consultation
Thank you for connecting with us. We want to do an initial diagnostic on your body pain and how we can help you. Kindly fill up these diagnostic questions that you can do in 5 minutes so we can quickly recommend your next best steps to reduce the pain in your body.
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Email *
Where did you hear about us? *
What is your best phone number to connect via Viber or Whatsapp? *
Current Symptoms Pre-Diagnosis
Answer the questions so we can understand the symptoms of your body pain and then find the root cause/s to help you be pain-free.
1.  What part of your body do you experience the body pain, tightness or stiffness right now?  (Check all that apply.) *
Required
2.  How long have you been experiencing this body pain, tightness or stiffness? (Think of the date [roughly] did your present problem start?) *
3.  How often do you experience this body pain, tightness or stiffness? *
4.  What is the level of pain each time you experience it from a scale of 1 to 10 as seen below *
Slight pain
Extreme pain
In your own words kindly describe the pain that you feel.  Describe your experience,  and/or hear yourself saying and /or picture in your mind  as you experience this pain?  
 *
5.  Was there an injury / surgery before this problem? *
If there was any significant injury / injuries that happened for which you were treated (including fractures, dislocations, and sprains), please briefly describe them and the approximate date of injury
Please list any previous surgeries or other conditions for which you were hospitalized, including the approximate date: 
6.  What solutions have you done so far to alleviate your pain?   (Check all that apply.) *
Required
7.  What activities make it worse?   (Check all that apply.)
8. In the past 3 months, have you had or do you experience any of these?  (Check all that apply.)
9.  Do you have previous X-Ray or MRI of the pain area in your body?
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