Edmonds Chiropractic Therapy Clinic

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How Can We Help You?

E-mail Address: * Do you have Pain, Weakness, Numbness or Tingling in the: * Choose all that apply Head - Headaches? Migraines?          Jaw: TMJ Neck: Upper or Lower                        Back: Upper, middle or lower Pelvis, Sacrum, Coccyx                     Shoulder Elbows: Tennis or Golfers                   Wrist: Carpal Tunnel Hands or Fingers Hips  Leg  Knees   Ankles   Feet or Toes In the recent past have you been? Check all that apply Tired, stressed or fatigued Depressed, anxious, moody Told you have a Thyroid condition Over-weight or Under-weight Having stomach or indigestion problems In chronic pain like Fibromyalgia or RA How bad are things now? Please Select 1-3 My symptoms are not that intense 4-5 Theres something wrong. I ignore it. 6-8 Things have gotten pretty bad 9-10 I need to renew and regenerate now How often do your symptoms occur? * Please Select Almost every day Once or twice a week A few times a month Often, especially when the weather changes What kind of treatment or technique do you prefer? Choose all that apply I like something hands-on like Chiropractic, Naturopathic or Accupuncture I am fond of Massage I enjoy stretching and exercising I take prescription drugs, but I do not like them How old do you hope to be when you pass away? 70-79 80-89 90-99 Over 100 First name: * Last name: * Male, Female - Age Male Female 10-19 20-29 30-39 40-49 50-59 60-69 70 and older Contact Phone Number * Free 15 minute Consultation - a $22.50 Value * Please choose one of the following: I would like my Free Consultation via Email. I prefer a Free Phone Consultation with the Doctor. Actually, I am just curious. I do not want a free consultation. * Required