Global Health Clinic Appointment Request

During your first appointment our physicians will perform a detailed physical examination and a medical history review. After a comprehensive health evaluation the doctors will assign the therapy treatment that is most beneficial for your particular condition. Since our doctors would like to give full attention to each patient’s condition, please estimate one to one and a half hours for your first appointment.

Address:

8269 W. Golf Rd
Niles, IL

Call us today!

(847) 299-7000

Hours of Operation:

Monday – Friday: 9am – 8pm
Saturday: 9am – 4pm

Name:

Phone #:

Address:

Email:

Please put a check next to your symptom(s):

	Back Pain		Hip Pain
	Neck Pain		Knee Pain
	Shoulder Pain		Other
	Joint Pain

How long have you had these symptom(s):

	1-2 weeks		1-2 month
	2 weeks – 1 month		Over 2 month

One the scale of 0 (= no pain) to 10 (=extreme pain), what is the intensity of your pain?


0	1	2	3	4	5	6	7	8	9	10

What is your insurance? Please check one of the following:

	Medicare		No Insurance
	Private Insurance		Other
	Auto Accident / Worker’s Comp

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Copyright © 2010 Global Health Clinic | Physical Therapy | Chiropractor | Acupuncture | Pain Management
As seen in Doctor Pages - Offers therapy for chronic back pain, neck pain and body pain to Chicagoland, Niles, Skokie, Glenview, Mount Prospect, Prospect Heights, Northbrook, Golf Mill, Franklin Park, Des Plaines, Morton Grove & Park Ridge area.