Los Angeles Chiropractor, Steven M. Gillis, D.C.

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Gillis Chiropractic Treatment Care

Serving Los Angeles,
Beverly Hills &
West Hollywood 

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Gillis Chiropractic Treatment Care

Serving West Hollywood, Beverly Hills, and Los Angeles

FREE Chiropractic Treatment Care Evaluation

Fill out the form below to have Dr. Steven Gillis, D.C. assess if chiropractic care can help you.  Your information is private and will not be sold, traded or used for any other purpose than the evaluation of your condition.

1. What is your main area of complaint? Headache, Neck, Upper Back, Middle Back, Lower Back, Hips, Shoulders, Arms, Legs, Other

2. How often does this complaint bother you?

3. Do you know what may have caused this complaint?

4. When it is at its worst, describe how it feels:

5. A. Has it been bothering you for more than a couple of days?

5. B. If "Yes", how long?

6. Does it prevent you from participating in any activities you enjoy?

6. B. If "Yes", which activities?

7. Have you tried any treatment for this problem, such as ice, heat, rest, motrin, muscle relaxers, physical therapy, or anything else which has not resolved this complaint as of yet? change to: Have you tried any self treatment for this problem, such as ice, heat, rest, pain medications, muscle relaxers, exercises, or anything else which has not resolved this complaint as of yet?

8. Have you been treated by any doctors or therapists for this condition?

9. What were the results of this treatment?

10. What is most important to you?

Name:
Phone:
Email:
Address:

Any additional information that might be important for my evaluation of your complaint or any specific questions for Dr. Gillis:

Beverly Hills, West Hollywood, Los Angeles Chiropractor
8281 Melrose Ave., #201, Los Angeles, California 90046
Los Angeles, Beverly Hills, West Hollywood Chiropractic Treatment Care:  (323) 655-8348
PainRelief@MyLosAngelesChiropractor.com
Copyright © 2003 Los Angeles Chiropractor, Steven M. Gillis, D.C.

Encino, Tarzana, Sherman Oaks Chiropractor
15760 Ventura Blvd., #820, Encino, California 91436
Encino, Tarzana, Sherman Oaks Chiropractic Treatment Care:   (818) 784-3737
PainRelief@MyLosAngelesChiropractor.com
Copyright © 2003 Los Angeles Chiropractor, Steven M. Gillis, D.C.

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