Head/Neck, MVA or Whiplash Screen

As per our discussion over the phone, prior to your appointment please complete this screening form to allow us to better establish your treatment plan before you arrive.

Please answer the following questions to the best of your knowledge

Do you have any of the following symptoms?

Rate from 0 being no symptoms to 6 being severe symptoms
Thank you for completing this form, our staff will review your form & contact you if there are any questions before your appointment. If you have any questions in the meantime, please call us at 403-314-4458