Health and Wellness Assessment

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Hi there, please fill out and submit the Health and Wellness assessment to help us better serve your needs.

21Questions

1
What are your main concerns today?Please tell us what brought you to our site today
Pain Relief
Stress relief
Emotional Balance
Health and Wellness
Pampering
2
Do you suffer from frequent headaches or migraines?Frequent meaning more than 2 a week
YESNO
3
Where are you experiencing pain?Check all that apply
Head/Neck
Shoulders/ Upper Back
Mid Back
Lower Back/Hips/Pelvis
Legs/Knees
Feet
Arms/Elbows/Hands
4
Do you take supplements for your health?supplements like Multivitamin, Omegas, Probiotics, Enzymes
YESNO
5
Do you drink at least half your body weight in water on a regular daily scheduleRule of thumb is drink 1/2 your weight in ounces daily
YESNO
6
Do you seek Bodywork on a regular scheduleMassage, Foot Zone, Cranial Sacral, Energy Balance work,
Weekly
Bi-weekly
Every 3 weeks
Monthly
Less than once every 6 Months
More than once every 6 Months
Once a year
Only when I injure myself or in pain
How often do you pamper your body and mind.
7
Rate your pain level on a scale of 1-1010 being sharp intense pain and 1 being mild discomfort
1
2
3
4
5
6
7
8
9
10
8
Do you currently visit a chiropractor for treatment?
YESNO
9
Do you suffer from Chronic or Acute painChronic: (Consistent symptoms for longer than 1 month) Acute: (1month or less or occurs off and on)
Chronic pain
Acute pain
Not sure
No Pain
10
Rate your stress level with the emojiHigh Stress......Medium Stress......Little Stress.......Very little Stress........No Stress
11
Have you been diagnosed or suffer from Sciatica?Nerve pain centralized deep in the buttocks or shooting pain down one or both legs.
YESNO
12
Have you been diagnosed or suspect you have Fibromylagia
YESNO
13
Are you currently experiencing symptoms of or been diagnosed with Plantar Fasciitis
YESNO
14
Are you experiencing pain or tension in the neck or jaw, and or ringing in the ear
YESNO
15
Have you ever had, or believe you have now rotator cuff injury or painThe rotator cuff is a group of 4 muscles located on the shoulder blade
Yes
No
I've had surgery on my rotator cuff
Not sure
16
Are you a athlete?
YESNO
17
Do you visit the gym or work out on a regular basis?Regular meaning more than 2 times a week.
YESNO
18
Have you experienced an accident, fall, or other type of head or neck injury?
YESNO
19
Please verify that you are human* This field is required.
20
Before continuing, please provide your name and email for a FREE copy of your assessment.
First Name
Last Name
Please enter your email
21
Is there anything else that we should know about that you are currently experiencing?
Huge
Large
Normal
Small
Ok
Ok
Should be Empty:

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