Where is the source of your pain / tingling/ numbness?

**Check all that apply*

Neck

Back

Hip

Legs

Knee

Arms

Shoulder

Headache

Other

On a Scale of 0 - 10 what is your level of pain?

(0 = No Pain, 10 = It can't get any worse)

0

1

2

3

4

5

6

7

8

9

10

What types of treatments have you tried to relieve your pain?

*Check all that apply

Physical Therapy

Chiropractic Care

Acupuncture

Steroid Injections

Massage

Exercise

Pain Medication

What areas of your life is the pain affecting?

*Check all that apply

Relationships

Sleeping

Sitting for more than 1 hour

Walking/Exercise/Recreation

Job responsibilities

Household chores

Driving

Emotional well-being

Is the pain / tingling / numbness:

*Choose ONLY 1

Rapidly getting better

Fluctuating but getting better

Seems to be getting better but improvement is slow

Neither getting better or worse

Gradually getting worse

Rapidly getting worse

How committed are you to fixing this pain TODAY?

*Choose ONLY 1

Very committed

Somewhat committed

Neutral

Not ready to commit yet

Full Name

Email

Phone

0%

Tap to Call 760-632-9736

Dr Neil Langschied

5120 Dixie Hwy

Suite 106

Louisville, KY 40216

Phone: (502) 237-4740

Back in Action Chiropractic Center - 500 Main Ave, Suite A, De Pere WI 54115

Disclaimer: Offer void where prohibited by law. Federal rules apply.
Not available to Medicare or Medicaid participants.
Limited to new patients only.

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Where is the source of your pain / tingling/ numbness?

*Check all that apply

On a Scale of 0 - 10 what is your level of pain?

(0 = No Pain, 10 = It can't get any worse)

What types of treatments have you tried to relieve your pain?

*Check all that apply

What areas of your life is the pain affecting?

*Check all that apply

Is the pain / tingling / numbness:

*Choose ONLY 1

How committed are you to fixing this pain TODAY?

*Choose ONLY 1

Full Name

Email

Phone

Dr Neil Langschied 5120 Dixie Hwy Suite 106 Louisville, KY 40216 Phone: (502) 237-4740

Back in Action Chiropractic Center - 500 Main Ave, Suite A, De Pere WI 54115

Copyright 2026. All Rights Reserved.

Privacy Policy | Terms of service

**Check all that apply*

Dr Neil Langschied

5120 Dixie Hwy

Suite 106

Louisville, KY 40216

Phone: (502) 237-4740