CONTENTS   Welcome to The Human Joint! Dr. Julie's Blog! The Human Joint Online Store NOW OPEN! What Is The Human Joint About? ARE YOU IN PAIN? Tell Us Where It Hurts--Health Survey Meet Dr. Julie Seymour D.C. About Chiropractic About The Activator READ what Dr. Julie has Written About Various Conditions Contact Us Map & DIRECTIONS to The Human Joint Dr. Seymour in the news #1 Dr. Seymour in the news #2 Our Favorite Links Seymour in the news #2 CONTACT The Human Joint! 40 West Louisiana Avenue Denver, Colorado 80223 Phone: 303-744-6567 Fax: 303-733-6567 Send Us E-mail © Copyright 1999-2008 Wellness First All Rights Reserved.

ARE YOU IN PAIN? Tell Us Where It Hurts--Health Survey   Here's your chance for a mini-consultation. If you fill out this form and submit it, we will write back with our opinions about your condition. Please be as truthful and accurate as possible. Items marked with * are required   * Where do you live? Denver Metro Area Colorado Another State Another Country   * Have you ever been to a chiropractor before? If so, with what result? Yes, I've been to a chiropractor before. No, I haven't been to a chiropractor before. Result was good. Result was unsatisfactory.   * Have you had an injury that is causing your present level of pain? Yes--at work Yes--in an auto accident Yes--while participating in recreation or sports Yes--other No   * How would you rate your level of pain or discomfort? Mild Moderate Severe Extreme   * Are you male or female? Male Female   * Do you have headaches? Never Occasionally Frequently Constantly   * Do you have neck pain? Never Occasionally Frequently Constantly   * Do you have pain between your shoulder blades? Never Occasionally Frequently Constantly   * Do you have low back pain? Never Occasionally Frequently Constantly   * Do you have numbness or tingling in an arm or a leg? Yes No   * How long have you been experiencing this condition? Less than one week More than one week More than one month More than six months More than one year More than five years More than ten years More than twenty years   * How would you rate your present general level of health? Excellent Good Average Below Average Poor   * Would you say you are under a lot of stress recently? Yes No   * Do you miss many days of work or play due to these conditions? Yes No   * How many times have you a cold or the flu in the past two years? Never Once Twice Three times Four times More than four times   * How old are you? 0-10 11-20 21-30 31-40 41-50 51-60 61-70 71-80 81-90 91-100   * Are you as physically "fit" as you'd like to be? Yes No   * If you could have relief from one of these conditions, which one would it be?   * How does the above condition interfere with your life?   * Do you have any medical conditions that we should know about? Yes No   * Please describe these medical conditions.   * If you have a question for us, please write it here. If no question, we won't know what you need.   * What is your name?     * What is your email address? (Required--otherwise we cannot respond)     Please press the "SUBMIT" button and your health survey will be emailed to us. Thank you.