Spine Health Assessment

Please select the option that best describes you.

Please complete your information to get started

First Name

Last Name

E-mail Address

Gender

Male
Female

Mobile Phone Number

Date of Birth

Click on the body part which is causing you the majority of your discomfort

Left

Right

How long have you had discomfort in your ?

Less than 3 months 3 months or more

Any other body part feeling discomfort? (click below if related to your )

Left

Right

None

Does your leg or buttock pain feel better when you do this?

Yes No

Indicate your pain level in your today

No pain

Worst possible pain

0 1 2 3 4 5 6 7 8 9 10

Thinking about the last 2 weeks tick your response to the following questions:

My pain has spread down my (s) at some time in the last 2 weeks Disagree Agree

I have had pain in the shoulder or neck at some time in the last 2 weeks Disagree Agree

I have only walked short distances because of my pain Disagree Agree

In the last 2 weeks, I have dressed more slowly than usual because of pain Disagree Agree

It’s not really safe for a person with a condition like mine to be physically active Disagree Agree

Worrying thoughts have been going through my mind a lot of the time Disagree Agree

I feel that my pain is terrible and it’s never going to get any better Disagree Agree

In general I have not enjoyed all the things I used to enjoy Disagree Agree

Overall, how bothersome has your pain been in the last 2 weeks?

Not at all Slightly Moderately Very much Extremely

Have you ever in the past received any of the following treatments, related to your discomfort?

None

Please carefully read all of the following options to see which may apply to you now:

Severe fall or accident within last 7 days

Personal history of cancer

Unexplained weight loss > 10 pounds in last 3 months

Difficulty urinating OR controlling urine OR loss of bowel control

Numbness where you wipe (anal or vaginal)

Worsening weakness in arms or legs

Fever > 101.5 degrees

Recent significant infection

History of IV drug abuse

Previous longstanding steroid use

Chest pain at rest

History of stroke or issues with vessels in neck

Compression fracture within last 3 months

None

Which activity would you like to improve with this program?

Daily Living
Activity Sports/Performance Activity

Please write the goal that you want to accomplish

Change goal type

50 characters left

Please select how well you can perform the goal of from 0 to 10:

0 1 2 3 4 5 6 7 8 9 10

How many chiropractic visits have you had in the past?

1 2-3 4-5 6-8 9-11 12 or more

Cancel

What surgeries have you had in the past?

Surgery location:

+ Add another surgery

Cancel Ok

How many strong pain meds (among the following: Norco, Percocet, Vicodin, Ultram, Tramadol, Hydrocodone, Ultracet, Oxycodone, Dilaudid, MS Contin, MSIR, Oxycontin, see more), in total, have you been taking per day?

Astromorph, Codeine, Darvocet, Darvon, Darvon, Demerol, Duragesic, Duramorph, Endocet, Fentanyl Patch, Fioricet, Fiorinal, Hydromorphone, Kadian, Lorcet, Lortab, Meperidine, Methadone, Morphine, Nubain, Numorphan, Oxymorphone, Percodan, Roxanol, Roxicet, Tylenol #3, Tylenol with Codeine, Vicoprofen

< 1/day 1-2/day 3-5/day > 6/day

None