Answer a few quick questions to get your $27 voucher.

What issues or symptoms are you experiencing?

**Check all that apply*

Pain

Numbness

Tingling

Burning Sensation

Have you been diagnosed with a bulging, herniated, degenerative, or other disc issue?

Yes

Where are you experiencing a disc issue?

**Check all that apply*

Neck

Upper Back

Mid-back

Lower Back

Have you had an MRI of your disc or spine?

Yes

Where is the source of your pain / tingling/ burning / numbness?

**Check all that apply*

Neck

Back

Hip

Legs

Knee

Arms

Shoulder

Headache

On a Scale of 0 - 10 what is your level of pain?

(0 = No Pain, 10 = It can't get any worse)

What types of treatments have you tried to relieve your pain?

*Check all that apply

Physical Therapy

Chiropractic Care

Acupuncture

Steroid Injections

Massage

Exercise

Pain Medication

What area(s) of your life is the pain affecting?

*Check all that apply

Relationships

Sleeping

Sitting for more than 1 hour

Walking/Exercise/Recreation

Job responsibilities

Household chores

Driving

Emotional well-being

Is the pain / tingling / burning / numbness:

Rapidly getting better

Fluctuating but getting better

Seems to be getting better but improvement is slow

Neither getting better or worse

Gradually getting worse

Rapidly getting worse

How committed are you to fixing this pain TODAY?

Very committed

Somewhat committed

Neutral

Not ready to commit yet

Full Name

Email

Phone

Tap to Call 760-632-9736

Dr Neil Langschied

5120 Dixie Hwy

Suite 106

Louisville, KY 40216

Phone: (502) 237-4740

Mt. Pleasant Chiropractic & Rehab - 5332 Spring Street, Racine WI 53406

Disclaimer: Offer void where prohibited by law. Federal rules apply.
Not available to Medicare or Medicaid participants.
Limited to new patients only.

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What issues or symptoms are you experiencing?

*Check all that apply

Have you been diagnosed with a bulging, herniated, degenerative, or other disc issue?

Where are you experiencing a disc issue?

*Check all that apply

Have you had an MRI of your disc or spine?

Where is the source of your pain / tingling/ burning / numbness?

*Check all that apply

On a Scale of 0 - 10 what is your level of pain?

(0 = No Pain, 10 = It can't get any worse)

What types of treatments have you tried to relieve your pain?

*Check all that apply

What area(s) of your life is the pain affecting?

*Check all that apply

Is the pain / tingling / burning / numbness:

How committed are you to fixing this pain TODAY?

Full Name

Email

Phone

Dr Neil Langschied 5120 Dixie Hwy Suite 106 Louisville, KY 40216 Phone: (502) 237-4740

Mt. Pleasant Chiropractic & Rehab - 5332 Spring Street, Racine WI 53406

Copyright 2026. All Rights Reserved.

Privacy Policy | Terms of service

**Check all that apply*

**Check all that apply*

**Check all that apply*

Dr Neil Langschied

5120 Dixie Hwy

Suite 106

Louisville, KY 40216

Phone: (502) 237-4740