FREE Chiropractic Treatment Care Evaluation

Fill out the form below to have Dr. Steven Gillis, D.C. assess if chiropractic care can help you.
Your information is private and will not be sold, traded or used for any other purpose than the evaluation of your condition.

1. What is your main area of complaint? (Headache, Neck, Upper Back, Middle Back, Lower Back, Hips, Shoulders, Arms, Legs, Other)


2. How often does this complaint bother you?
Constantly Daily 3 times a week Once a Week Twice a Month Once a Month

3. Do you know what may have caused this complaint?
Auto Work Sports Injury Fall Other

4. When it is at its worst, describe how it feels:


5. A. Has it been bothering you for more than a couple of days?
Yes No

5. B. If "Yes", how long?


6. Does it prevent you from participating in any activities you enjoy?
Yes No

6. B. If "Yes", which activities?


7. Have you tried any self treatment for this problem, such as ice, heat, rest, pain medications, muscle relaxers, exercises, or anything else which has not resolved this complaint as of yet?


8. Have you been treated by any doctors or therapists for this condition?


9. What were the results of this treatment?


10. What is most important to you?
Initial Relief of Symptoms Correction of Problem Maintaining Wellness

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Any additional information that might be important for my evaluation of your complaint or any specific questions for Dr. Gillis: