Richards Family Chiropractic Health Survey

Privacy Statement: Note that all information gathered on our questionnaire isn't sold, or used in any manner other than for our office's statistical purposes. Your privacy is just as important to us as it is for you.

*denotes required field

Name:*
E-mail*
Address:
City:
State:
Zip Code:
Home Phone:	AC: Phone:
Age:
Occupation:
Number of Children:

Please Answer All Questions.

Do you have trouble relaxing or falling asleep? YesNo

Are you exhausted at the end of the day? YesNo

Do you have weight problems? YesNo

If so, are you underweight? YesNo

If, are you overweight? YesNo

Do you take pain relievers, antacid, tranquilizers, or any other relief oriented medicine? YesNo

Do you exercise less than two times weekly? YesNo

Do you feel you are a nervous or tense person? YesNo

Do you lose your temper or become angry easily? YesNo

Do you rely on caffeine or sugar stimulants? YesNo

Have you ever had an auto accident or been injured on the job? YesNo

Do any members of your immediate family have back and/or neck problems? YesNo

Do you have any other health problems of which you are aware? YesNo

If yes, explain,

Please mark any and all areas of pain
and/or discomfort for the items below.
	Past	Now
Low Back Pain
Leg Pain
Neck Pain
Shoulder and Arm Pain
Disc Problems
Whiplash Neck Injuries
Arthritis
Pinched Nerve
Headache
Scoliosis
Dizziness
Numbness or Tingling in Arms or Legs
Menstrual Pain
Sinus or Allergies
Deep Muscle pain and stiffness

Do we have permission to call you about your survey? (Western NC residents only)	YesNo
If you live outside Western North Carolina, would you like us to put you in touch with a chiropractor in your area?	YesNo N/A

|Chiropractic in the News| |The TENs Unit|

Do you have trouble relaxing or falling asleep?	YesNo
Are you exhausted at the end of the day?	YesNo
Do you have weight problems?	YesNo
If so, are you underweight?	YesNo
If, are you overweight?	YesNo
Do you take pain relievers, antacid, tranquilizers, or any other relief oriented medicine?	YesNo
Do you exercise less than two times weekly?	YesNo
Do you feel you are a nervous or tense person?	YesNo
Do you lose your temper or become angry easily?	YesNo
Do you rely on caffeine or sugar stimulants?	YesNo
Have you ever had an auto accident or been injured on the job?	YesNo
Do any members of your immediate family have back and/or neck problems?	YesNo
Do you have any other health problems of which you are aware?	YesNo
If yes, explain,