253-854-3820 drallan@kechiro.com

Survey

Is Non-surgical Spinal Disc Decompression For You?  Take this short survey to find out.

 

    Your Name (required)

    Your Email (required)

    What is Your Occupation?

    In Which Areas Are you Experiencing Pain?

    Lower Back
    Neck
    Hips
    Calf
    Foot
    Shoulder
    Upper Arm
    Lower Arm
    Wrist
    Hand
    Fingers

    Have You Experienced Any of the Following in the Last 6 Months?

    Headaches
    Dizziness
    Arm or Hand Pain
    Numbness and Tingling in Extremities
    Pain Between Shoulders
    Low Back Pain
    Pain Down the Legs
    Allergies or Asthma
    Painful and stiff joints

    Please Answer the Following Questions About the Pain You Are Experiencing.

    Do you believe that your pain is getting worse?
    Does your pain slow you down or stop you from performing daily activities?
    Does your pain cause you to take medication more often for pain?
    Does your pain cause you to miss work?
    Does your pain make you think about having surgery?
    Are you scared of the outcome of surgery?

    Please Describe The Frequency of Your Symptoms

    Intermittent | Occasional | Frequent | Constant

    Have You Ever Visited Any of the Following?

    Primary Doctor
    Neurologist
    Orthopedic Specialist
    Chiropractic
    Acupuncture
    Physical Therapist
    Massage Care

    Do You Have Access to Any Current Imaging?
    CAT ScanMRIXray

    Have You Ever Had Back Surgery?YesNo

    Have You Ever Had Neck Surgery?YesNo

    If you do qualify as a non-surgical disc decompression candidate and there was a way to help relieve your pain using one of our advanced non-surgical treatment programs, would you be willing to schedule a consultation?
    YesNo

    If so, When is the best time to contact you?
    MorningAfternoonEvening