OLD TOWN CHIROPRACTIC
Matthew E. Goltl, D.C., P.A.

Old Town Center        MAP
800 E 1st Street, Suite 350
Wichita, KS 67202
Tel: 316-262-6665
Fax: 316-262-6649

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Submit Your Health Survey

Are you interested in improving your health? This survey
will help determine if Chiropractic care is right for you.

* indicates required information.

*Name

*Age

*Occupation

*Phone (Home)

*Phone (Work)

*Address

*City, State, Zip

*E-mail Address

 

 

How often do you excercise?





 

Do you see a health care professional regularly?   

If yes, who do you see?

   

Please check any symptoms are currently experiencing or have experienced in the last 6 months:

Headache
Neck pain/stiffness
Dizziness
Back pain
Nervousness
Tension
Irritability
Chest Pain
Ears ringing
Fainting
Loss of balance
Sleeping problems
Head too heavy
Loss of memory
Pins and needles/numbness
      in arms, hands, and/or fingers

Pins and needles/numbness
      in legs, feet, and/or toes
Shortness of breath
Eyes sensitive to light
Buzzing in ears
Loss of smell/taste
Diarrhea
Constipation
Feet/hands
Stomach upset
Face flushed
Cold sweats
Fever
Fatigue
Depression

Do your symptoms affect:
Quality/quantity of sleep
Ability to perform job duties
Ability to participate in recreational activities

If these symptoms apply to you, you may find Chiropractic care beneficial.

We can help you using our gentle, non-invasive methods to enhance your over all health and well being.

   

I would like to come to Old Town Chiropractic for a complete evaluation. Please contact me to schedule an appointment.

I would like Old Town Chiropractic to contact me to schedule a FREE CONSULTATION to discuss my heath care concerns.

I am interested in receiving literature in the mail from Old Town Chiropractic.