369 Colony Blvd.

The Villages, FL 32162

(352) 430-3355

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New Patient Online Form

dull with episodes of sharp
sharp
dull
burning
tingling
ache
stiff
numb
yes
no
any movement
bathing
bending
climb stairs
computer use
cooking
cough/sneeze
driving
fall or stay asleep
getting out of bed
get out of bed
get out of chair
house chores
lifting
look over shoulder
rest
sit
stand
sit-to-stand
stand in place
turn
walk
yardwork
chiropractic
cold packs
exercise
heat
over-the-counter medication
prescription medication
nothing
pacemaker
blood thinners
joint replacements
osteoporosis
spine surgery
recent imaging (x-ray, MRI, CT-scan)
none of these
arthritis
back problems
neck problems
osteoporosis
none of these
dizziness
numbness
pins & needles sensation
stroke
none of these
diabetes
thyroid problems
none of these
cancer
diabetes
heart disease
stroke
none of these

In order to properly assess your condition, we must understand how much your problem has affected your ability to manage everyday activities. For each item below, please check the box which most closely describes your condition right now.

0. No pain
1. Mild pain
2. Moderate pain
3. Severe pain
4. Worst Pain possible pain
0. Perfect sleep
1. Mildly disturbed sleep
2. Moderately disturbed sleep
3. Greatly disturbed sleep
4. Totally disturbed sleep
0. No pain; no restrictions
1. Mild pain; no restrictions
2. Moderate pain; need to go slowly
3. Moderate pain; need some assistance
4. Severe pain; need 100% assistance
0. No pain on long trips
1. Mild pain on long trips
2. Moderate pain on long trips
3. Moderate pain on short trips
4. Severe pain on short trips
0. Can do usual work plus unlimited extra work
1. Can do usual work; no extra work
2. Can do 50% of usual work
3. Can do 25% of usual work
4. Cannot work
0. Can do all activities
1. Can do most activities
2. Can do some activities
3. Can do a few activities
4. Cannot do any activity
0. No pain
1. Occasional pain, 25% of the day
2. Intermittent pain, 50% of the day
3. Frequent pain, 75% of the day
4. Constant pain, 100% of the day
0. No pain with lifting heavy weight
1. Increased pain with lifting heavy weight
2. Increased pain with lifting moderate weight
3. Increased pain with lifting light weight
4. Increased pain with lifting anything
0. No pain; any distance
1. Increased pain after 1 mile
2. Increased pain after 1/2 mile
3. Increased pain after 1/4 mile
4. Increased pain with all walking
0. No pain after several hours
1. Increased pain after several hours
2. Increased pain after 1 hour
3. Increased pain after 1/2 hour
4. Increased pain with any standing

Thank you for taking the time to fill out this form.

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Office Hours

Our Regular Schedule

Office Hours

Monday:

8:00 am-12:00 pm

2:00 pm-4:00 pm

Tuesday:

8:00 am-12:00 pm

Wednesday:

8:00 am-12:00 pm

2:00 pm-4:00 pm

Thursday:

8:00 am-12:00 pm

Friday:

8:00 am-12:00 pm

2:00 pm-4:00 pm

Saturday:

9:00 am-12:00 pm

Sunday:

Closed