Welcome to Dr. Lee’s online Health Survey

The information you provide in this survey form will allow Dr. Lee to address your specific health concerns. Your name and Email address are required. The remaining fields are optional.

This is a secured page. Your information is considered highly confidential and will never be shared with a third-party.

Please provide the following information:

Full Name:

* required

E-mail:

* required

Street Address:

Address 2:

City:

State:

Zip Code:

Daytime Phone:

Evening Phone:

Additional Information:

Date of Birth:

Sex:

Male Female

Height:

Weight:

lbs.

Select any of the subluxation indicators below
(check all that apply):

Low Back Pain
Pain between shoulder blades
Neck pain
Tension across shoulders
Tension/Migraine headaches
Fatigue
Numbness/tingling in arms or hands
Numbness/tingling in legs or feet
Dizziness
Ringing in ears
Nervousness
Difficulty sleeping
Allergies
Digestive problems
Weight trouble

Which of the above symptoms is the worst?

How long have you experienced these symptoms?

Additonal Comments:

Before you click the Submit Form button, select the method of response that you prefer (phone or email). If you prefer to be contacted by phone, please be sure to include your phone number above.

Select this option if you would like us to call you by phone.

Select this option if you prefer to be contacted by email only.

 

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