ChiroDrs | AcuX

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Thank you for considering care at

the ChiroDrs @ Rapha Clinic,

an Integrative Healthcare Centers.

Please complete the following questionnaire to effectively and efficiently offer and

schedule your First appointment with us.

First Name

Email

Last Name

Phone

1. What is your primary reason for seeking an appointment?

2. What is the intensity of your current condition (0-10)?

0-3

3-7

7-10

3. Is the condition worse in the morning or evening?

Morning

Evening

4. What makes your condition worse?

5. What makes your condition better?

6. When was your recent evaluation for the current condition?

7. When was the most recent adjustment or treatment(s) for the current condition?

8. Are you currently receiving any treatment(s) for the condition?

9. Do you have a health insurance plan?

Yes - Please check if my plan will cover Acupuncture and other services you offer

No - Please offer self pay rates for my future appointments.

Not Interested

Upload File

Or Upload Front of Ins. card

Max File Size 15MB

Upload File

Uplad Back of Ins. card

Max File Size 15MB

10. Where is your Preferred Location? (check all that apply)

Arlington / Rosslyn Metro

Lansdowne / Leesburg

11. When is your preferred days and times for your treatment? (check all that apply)

Mon - Wed

Thurs - Fri

10 am - 3 pm

3 pm - 8 pm

Schedule me any time

12. Other info or comments

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