My Chiropractic Story

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I first consulted this office for: (state original problem)

I had this problem for: (# of days, months, years)

My previous treatments for this problem was:

I first heard about this office from:

I tried chiropractic because:

My first impression of the office was:

My first impression of the doctor was:

My first impression of chiropractic adjustments was:

My results with chiropractic were:

Chiropractic has also helped: (state any other problems)

I know chiropractic also helps other conditions such as:

Now I feel: (describe your feelings about chiropractic)

Any other comments? Let us know what you think!

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