LifeWorks Integrative Health's Complimentary $20 Special*
Your Name
*
First Name
Last Name
Telephone
*
xxx-xxx-xxxx
E-mail
*
Zip Code
*
City
Date of Birth
*
-
Month
-
Day
Year
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Check all of the symptoms you have experienced in the past 6 months:
Headaches
Neck Pain
Back Pain
Leg or Hip Pain
Arthritis
Shoulder/Arm Pain
Knee Pain
Irritability
Dizziness
Problems Sleeping
Sciatica
Chronic Pain
Tingling/Numbness in Arms or Legs
Other
Which of the above symptoms concerns you the most?
Concerning that symptom, how long have you experienced it?
Are any of the above selected symptoms the result of a recent auto accident?
*
Yes
No
■
This package is valid for local residents only (living or working in the Kansas City area).
■ One package per person. Not available for individuals on federal programs such
as KanCare or Medicaid.
■ This is not an inducement for care
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