Patient Questionnaire - Need Chiropractor?

Do you need a chiropractor?

Answer our short and easy questionnaire below. Pick the one statement that most closely describes your problem.

PAIN INTENSITY

  1. I have no pain.
  2. I can tolerate the pain without drugs.
  3. I can manage my pain with the help of drugs.
  4. Pain relievers give me no comfort.

LIFTING

  1. I have no pain when lifting.
  2. I have slight pain when I lift.
  3. Pain prevents me from lifting heavy objects.
  4. I can only lift light to moderate objects.
  5. I can barely lift anything.

     

STANDING

  1. I can stand up for extended periods.
  2. I cannot stand for more than one hour without pain.
  3. I cannot stand for more than 30 minutes without pain.
  4. I cannot stand at all without pain.

HEADACHES

  1. I have no headaches.
  2. I have slight headaches.
  3. I have moderate to severe headaches.
  4. I have headaches all the time.

SOCIAL LIFE

  1. My social life is normal.
  2. My social life is normal, but with slight pain.
  3. My social life is limited by pain.
  4. Pain prevents me from having a social life.

Total up your score. If your score is 3 or above, please give our office a call 952-931-9867 to set up an initial consultation. We look forward to assisting you in achieving better health through chiropractic.

Contact Us by calling (952)931-9867 or using the form below

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