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.
42-55 = Get to the Chiropractor NOW!
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