Make your own free website on Tripod.com

Response Form

Chiropractic Questionnaire

Please feel free to call with any questions or concerns. We would be happy to provide you with more information on chiropractic care or schedule you for a free exam and computerized spinal thermographic  reading.

How did you find this site?

Have you tried alternative medical therapies before?

Answer A - search engine

Answer A - yes, chiropractic

Answer B - referral

Answer B - yes, herbs

Answer C - other link

Answer C - no, never

Do you have backaches, asthma, migraines or ear infections?

Are you currently on any prescription medication?

Answer A - yes

Answer A - yes

Answer B - no

Answer B - no

Answer C - sometimes

Any Questions of Comments regarding Chiropractic Care:

"At least 100,000 people die annually from reactions or complications from medication. This combined with deaths resulting from other medical procedures raises the estimated total to between 156,000 to 260,000 deaths each year in the United States alone."

* a 1964 study by Dr. Elihu Schimmell, MD, who conducted what is known as the Yale New Haven Hospital Study.

Name:

Address:

City:

State/Prov:

Country:

Zip/Post. code:

Phone:

E-mail:

Dr. Steve Wilson
Wilson Chiropractic Family Center
3655 Adams Avenue
San Diego,  CA 92116
sueno@incom.net

© Publicity + , 1999