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.

At what level are your symptoms currently at? *

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

Neck

Back

Knee

Shoulder

Arms

Legs

Other

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

Chiropractor

Pain Management

Neurologist

Orthopedic Surgeon

General/Family Doctor

How did the symptoms 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 symptoms? *

Yes

What areas of your life are being affected by your current symptoms? (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 these symptoms/symptom TODAY? *

Very committed

Somewhat committed

Neutral

Not ready to commit yet

Which insurance (if any) do you have? *

United Healthcare
Aetna
Cigna
Humana
BCBS
No Insurance
Other
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What kind of work do you do? *

What is your ZIP code? *

Full Name *

Email *

Phone *

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 2340 Mountain Shadow Dr, Duluth MN 55811. *

Yes

2340 Mountain Shadow Dr. Duluth, MN 55811

Call Us Today: (218) 506-5309