Lang Chiropractic - Chiropractor In Abington, PA, USA :: Egoscue Method Client Intake Form

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First Name *

Last Name *

Current Symptoms (Include L.O.D.S.)

Occupation:

Do You Have Health Issues?

Are You Currently On Any Pain Or Other Medications?

What Position, If Any, Increases Your Pain?

What Position, If Any, decreases Your Pain?

What Are Your Favorite E-cises?

Do You Have Trouble Sleeping Due To Pain?

What Time Of Day Do You Have The Most Pain?

Do You Feel Better Or Worse With Movement?

What Kind Of Exercise Or Activities Are You Involved In?

What Is Your Primary Reason For Joining The Program?

Short-Term Goals?

Long-Term Goals?

Success To Date?

Time Willing To Invest In Menu?

What Time Is Best For Your Menu? (AM/PM)

Type Of Learner? (Auditory, Visual, Kinesthetic)

Enter the verification code in the box below.

Verification Code: *

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960 Old York Road, Suite 201
Abington, PA 19001
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Clinic Hours

Mon	10:00 - 1:00	2:30 - 7:00
Tue	-	2:30 - 7:00
Wed	10:00 - 1:00	2:30 - 7:00
Thu	-	2:30 - 7:00
Fri	10:00 - 1:00	-
Sat	10:00 - 1:00	-
Sun	Closed	Closed

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