Westwood Family Chiropractic Quiz

1446 High Street

Westwood, MA 02090

Do you want better health and vitality? 💪

Do you have a health concern? 😷

WE CAN HELP!!!

Please complete the 30-Second Quiz below to see if You Qualify To Get a Complimentary Comprehensive Health Consultation with Digital Posture Analysis!

Note: A form will appear below in a few seconds. Please fill that & start your quiz.

First Name *

Last Name *

Phone *

Email *

Campaign Source

Offer

How long have you been experiencing discomfort? *

Just recently

0-6 months

6-12 months

More than 12 months

Is there anything that makes it feel worse? *

Sitting

Walking

Computer Work

Sleeping

Electrotherapy

No, nothing helps

What are your current symptoms? *

back pain

neck pain headaches/migraines

neuropathy

disc herniation

scoliosis

vertigo

How painful/uncomfortable are your symptoms at it's worst on a 1-10 Scale *

0-1

2-3

4-5

6-7

8-9

10+

Please Tell Us About Yourself *

Male

Female

Age *

25 to 34

35 to 44

45 to 54

55 to 64

65 and above

How is this issue affecting your quality of life? *

At the end of the day, you will realize better health, well being and vitality is possible through your own body's healing capability.

THE PATIENT AND ANY OTHER PERSON RESPONSIBLE FOR PAYMENT HAS THE RIGHT TO REFUSE TO PAY, CANCEL PAYMENT OR BE REIMBURSED FOR PAYMENT FOR ANY OTHER SERVICE, EXAMINATION OR TREATMENT WHICH IS PERFORMED AS A RESULT OF AND WITHIN 72 HOURS OF RESPONDING TO THE ADVERTISEMENT FOR THE FREE, DISCOUNTED OR REDUCED FEE SERVICES, EXAMINATION OR TREATMENT.

1446 High Street

Westwood, 02090

(781) 427-2202

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