Loading...
  • 500 SW 7th St. Suite 205,Des Moines, Iowa, 50309
,
515.971.6143

Chiropractic Questionnaire

Chiropractic Questionnaire

Is Chiropractic Right For Me?

Spinal Health Chiropractic Questionnaire

DIRECTIONS: Chiropractic Questionnaire

Welcome to the spinal health chiropractic questionnaire! This chiropractic questionnaire is designed to determine the urgency of which you should have your spine evaluated. The higher the score, the more likely it is that your spine has underlying bio mechanical dysfunction. If left untreated, can lead to significant spinal health problems requiring large amounts of time and money to be fixed (if it can be fixed at all.)

To find out where you stack up in spinal health, pick a number between 1-5 for each question that describes your condition related to the question. At the end, add up all the numbers you picked. Then, using the key at the end, use that number to determine your spinal health and how urgent it is for you to see a chiropractor.

How active are you in your profession?

1: My job has me up and moving almost all day performing a wide variety of physical tasks.

2: My job has me moving half the day and at a desk the other half.

3: My job has me standing and moving almost all day performing repetitive physical tasks.

4: My job has me at a desk or seated most of the day.

5: My job has me in a vehicle many hours.

What is your family spinal health history?

1: Most of my family has no spinal health problems.

2: A couple of my close relatives have had mild spinal health conditions such as mild arthritis or degeneration as they got older.

3: A couple of my close relatives have dealt with mild spinal health conditions for most of their lives including back pain, arthritis, degeneration, or scoliosis. Does not include acute injuries.

4: Many of my close relatives have spinal health conditions and deal with spinal, hip or head pain frequently not due to an acute injury.

5: Most of my close relatives have severe spinal, hip or head pain most of the time which started at a young age and was not due to an acute injury.

How often do you have spine, neck, head or hip pain without any known cause?

1: I never have spine, neck, head or hip pain without any known cause.

2: I have had spine, neck or hip pain once without any known cause and it went away within 3 days.

3: I have had spine, neck, head or hip pain a few times without any known cause.

4: I have spine, neck, head or hip pain often without any cause. It goes away but takes a while sometimes.

5: I have spine, neck, head or hip pain almost all the time and I don’t know what I did to cause it.

How often do you get headaches?

1: I never get headaches.

2: I hardly ever get headaches and when I do they last only a couple hours.

3: I get headaches about once or twice per month.

4: I get headaches once per week.

5: I get headaches multiple times per week.

How is my natural head posture?

1: When I take a picture of myself from the side in the mirror in my natural posture, my ears are directly over my shoulders.

2: When I take a picture of myself from the side in the mirror in my natural posture, my ears are slightly in front of my shoulders.

3: When I take a picture of myself from the side in the mirror in my natural posture, my ears are in front of my shoulders, my shoulders are rounded and my mid back is starting to round.

4: When I take a picture of myself from the side in the mirror in my natural posture, my ears are in front of my shoulders, my shoulders are rounded, my mid back is starting to round and there is a small pillow like hump where my neck meets my shoulders over the spine. I can stand up straight but its not comfortable.

5: When I take a picture of myself from the side in the mirror in my natural posture, my ears are well in front of my shoulders, My mid back is very rounded, I have a visible hump at the base of my neck where it meets my shoulders and it hurts to touch it. I feel like I cant stand up straight.

How often do you sit on a wallet in your back pocket OR carry your purse on the same shoulder?

1: I never sit on my wallet OR I alternate the shoulder I carry my purse on often.

3: Sometimes I set on my wallet OR I often carry my purse on the same shoulder.

5: I sit on my wallet often OR I always carry my purse on the same shoulder.

Are you overweight?

1: I am not overweight.

2: I am slightly overweight.

3: I am overweight.

4: I am very overweight.

5: I am obese.

How often and how vigorous do you exercise?

1: I exercise vigorously 3+ times for 30+ min every week.

2: I exercise 3+ times for 30+ min every week.

3: I exercise at least once per week for 30+ min.

4: I exercise a couple times per month.

5: I don’t get much exercise.

Have you ever had a spinal injection to relieve pain (epidural for child birth included) OR spinal surgery to correct scoliosis?

1: I have never had a spinal injection OR spinal surgery to correct scoliosis.

5: I have a spinal injection OR a spinal surgery to correct scoliosis.

How often are you on your cell phone? (Be Honest!;)

1: Never more than 10 min at 1 time.

2: Never more than 20 min at 1 time.

3: Sometimes up to a half hour at a time.

4: Sometimes I am on my phone for an hour straight.

5: I am on my phone for over an hour straight often.

Are you currently on a chiropractic spinal maintenance program?

1: Yes I currently am on a regular chiropractic spinal maintenance schedule.

3: I am not on a regular chiropractic spinal maintenance schedule but I try to get adjusted once every month to 2 months.

5: I am not on a regular chiropractic maintenance schedule and I haven’t been adjusted in over 2 months.

Chiropractic Questionnaire

Questionnaire Key

Now add up all the numbers from your answers. It should be a number between 11 and 55. Below are the interpretations of what your score means

11-20 = Great! if you got a score in this range that means you do a great job of taking care of your spine. Ensuring your spine continues functioning at a high level and without pain should be an easy endeavor for you. Now, don’t let it ever become a problem. Regular maintenance adjustments are all your spine needs to continue functioning at a high level! Congrats!

21-30 = Good, but can be improved! It is likely your spine is in the initial stages of dysfunction. There are likely mild restrictions in the spine leading to mild problems. If left unchecked, spinal problems, even while small, will always get worse if not attended to properly. A short, aggressive acute care chiropractic regimen is likely to resolve your symptoms so long as there are no underlying health conditions.

31-40 = Time to get into the chiropractor. If your score is in this range it means a mechanical problem in your spine has been left unattended to and allowed to progress to an actual spinal condition. Failure to address the issue will lead to it needing a serious intervention such as surgery or constant medication just to dull the pain.

42-55 = Get to the Chiropractor NOW!

If you are curious if chiropractic is the right choice for you, click on the new patients portal button above to learn how to schedule an appointment. We are the #1 reviewed and recommended chiropractic clinic in Downtown Des Moines. The clinic has a guaranteed free on-site parking lot. NO SURPRISE FEES. We also offer free consultations if you still have any questions about chiropractic care. Thank you for taking our chiropractic questionnaire.

Privacy Settings
We use cookies to enhance your experience while using our website. If you are using our Services via a browser you can restrict, block or remove cookies through your web browser settings. We also use content and scripts from third parties that may use tracking technologies. You can selectively provide your consent below to allow such third party embeds. For complete information about the cookies we use, data we collect and how we process them, please check our Privacy Policy
Call Now ButtonCall Us