Thank you for submitting a request for the New Patient Special.

We will contact you shortly. Next, please fill out the pain assessment to get started.

What is the level of pain you are experiencing? (10 being most severe) *

Full Name *

Email *

Phone *

Where is the source of your pain? (check all that apply) *

Neck

Back

Knee

Shoulder

Arms

Legs

Other

What type of doctors have you seen for pain? (check all that apply) *

Chiropractor

Pain Management

Neurologist

Orthopedic Surgeon

General/Family Doctor

How did the pain begin? (check all that apply) *

Accident at Home

Vehicle Accident

Accident at Work/Work-Related

"Just Began"

After Surgery

"Came on Gradually"

Sports Related

Have you had any surgeries related to your existing pain or any prior pain condition? *

Yes

The pain that you are experiencing is affecting what areas of your life? (check all that apply) *

maintaining a safe environment

communication

breathing

eating and drinking

elimination

washing and dressing

mobilization

working and playing

expressing sexuality

sleeping

daily parenting

finances

household chores

self-worth/value

physical well-being

emotional health

How committed are you to fixing this pain TODAY? *

Very committed

Somewhat committed

Neutral

Not ready to commit yet

Which insurance (if any) do you have? *

Mayo Medica

BCBS

Health Partners

uCare

Medicare

Cigna

What kind of work do you do? *

What is your ZIP code? *

PLEASE ACKNOWLEDGE THE FOLLOWING STATEMENT: "I will NOT miss my appointment once it is scheduled because I respect your time and I understand it is not fair to others who would have scheduled in my place if I don't show up." *

Yes

PLEASE ACKNOWLEDGE THE FOLLOWING: I understand that your office is located at 2766 Commerce Drive Northwest Suite C Rochester, MN 55901 *

Yes

2766 Commerce Drive Northwest Suite C

Rochester, MN 55901

Call Us Today: (507) 639-0474

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