Free Consultation Request Form - Pain Management Wheaton

This information is confidential and will be used solely for purposes of diagnosis and treatment. It will not be shared with or distributed to any outside sources.

Upon submission of this survey, you will be contacted within five business days to set up your free, in-person consultation. Please assure that you include correct E-Mail and Phone number information to assure we are able to respond.


Name: Age: Phone (Home): (Work):
E-Mail:
Address: City: State: Zip:
Occupation: # Hours per week currently working:
Spouse Occupation: # Hours per week currently working:
Headaches/Tension Irritability Elbow Pain Dizziness
Fatigue/Tired Depression Shoulder Pain Allergies
Pain Anywhere in the Body Anxiety Hip Pain Frequent Colds
Digestive Disturbance Menstrual Problems Pain Between
Shoulder Blades		 Tension Across
Top of Shoulders
Constipation Fertility Issues Knee Pain Numbness/Tingling in
Arms or Hands
Urinary Problems Low Back Pain Ankle/Foot Pain Numbness/Tingling in
Legs or Feet
GERD/Heartburn Neck Pain Ringing in Ears Weight Trouble
Difficulty Sleeping Wrist/Hand Pain Nervousness Other
Which of the above bothers you the most?
How long have you been bothered by the condition?
Describe how it feels or affects you when it is at its worst?
Moody Decision Making Lose Patience with Spouse or Children
Depressed Poor Attitude Restricted Household Duties
Irritable Decreased Productivity Hinders Ability to Exercise or
Participate in Sports
Sleeping with Interruptions Exhausted at End of Day Hinders Ability to Participate in Hobbies or
Other Desired Activities
Restricted on Daily Activities Unable to Work Long Hours  
If you checked any of the above items, your organs are probably not functioning as well as they could, and your energy is probably not flowing as smoothly as it could be.

ACUPUNCTURE AND CHINESE HERBAL MEDICINE CAN HELP YOU because they gently and naturally treat the body to remove the stress and imbalance that CAUSE health problems.

WOULD YOU LIKE TO GET RID OF THE PROBLEM? YES    NO

If your answer is Yes, there are several alternatives available to you. Please check the most appropriate for you:
I would like to come to the Acupuncturist's office for an initial evaluation and consultation. There is NO CHARGE for this visit. This will allow me to find out if I can be helped by the Staff at County Farm Health without any financial barriers.