Health Survey Form

Painless Chiropractic of Fenton's: Back Pain Risk Assessment

Note from our Fenton Chiropractor:

There are numerous factors associated with the development of mid to lower back pain, many of which can be effectively controlled, even corrected while some cannot. This free risk assessment will only take you about 7 min. to complete. Once finished, you will receive a personalized and confidential breakdown that will help you:

A) Assess your current health status and identify those medical and/or lifestyle conditions that may lead to the development of dis-ease.
B) Take action to reduce your level of risk, including making you aware of the many services available through the successful protocols offered by the spinal care team at Painless Chiropractic.
C) Receive, continued, up to date health information and events happening within our organization.

Knowing your risk profile will enable you to take control of your health and provide you with the best defense against disc degeneration and spinal disorders.

Are you a Painless DC Employee? *

Please read the following disclaimer and indicate below if you agree to all terms: *

I AGREE TO THE DISCLAIMER
I AGREE TO THE DISCLAIMER

Terms and Conditions

Age

Gender

Zip Code

The first attack of low back pain typically occurs between the ages of 30 and 40. Back pain becomes more common with age.

What is your ethnic origin? (optional)

Ethnic Origin

Some kinds of back pain, such as disc disease, can be inherited. African American women, for example, are two to three times more likely than white women to develop spondylolisthesis, a condition in which a vertebra of the lower spine slips out of place.

What is your height? *

Feet:

Inches:

What is your weight? *

Pounds

Additional weight, especially in the stomach, shifts your center of gravity forward and puts additional strain on your back muscles. It is recommended to keep within 10 lbs. of your ideal weight for a healthier back. It is also possible to be too thin. Extreme thinness can be accompanied by low bone mass, putting you at risk for osteoporosis.

Have you unexpectedly lost or gained weight in the past year? *

Weight Status

Losing weight while developing a healthy attitude and learning to move your body properly while you do daily activities, particularly those involving heavy lifting, pushing, or pulling, are sometimes part of the treatment plan for people with back pain.

Do you use tobacco products or smoke cigarettes? *

Tobacco Smoking Status

People who smoke are more likely than people who don't smoke to have low back pain.

Do you currently have pain, discomfort, or stiffness in your back? *

Do you currently have pain Status

Is your pain worse in your legs or back? *

Is your pain worse in your legs or back Status

Has your back pain spread down your leg(s) at some time in the last 2 weeks? *

Has your back pain spread down your leg(s) Status

Have you had pain in the shoulder or neck at some time in the last 2 weeks? *

Have you had pain in the shoulder or neck Status

Have you only been able to walk a short distance because of your back pain? *

Have you only been able to walk a short distance because of your back pain Status

In the last 2 weeks, have you had to dress more slowly than usual because of back pain? *

In the last 2 weeks, have you had to dress more slowly than usual because of back pain Status

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

Which of the following best describes your ability to lift heavy objects/weights? *

Which of the following best describes your ability to lift heavy objects/weights Status

Are these symptoms worse after a period of inactivity such as getting out of bed in the morning, riding in a car for long distances, sitting in a movie theater or at a sporting event? *

Are these symptoms worse after a period of inactivity Status

Pain can occur when, for example, someone lifts something too heavy or overstretches, causing a sprain, strain, or spasm in one of the muscles or ligaments in the back.

Do you take prescription or over the counter medication for relief of your back pain? *

Do you take prescription or over the counter medication

A wide range of medications are used to treat chronic back pain. Some are available over the counter. Others require a doctor’s prescription.

Is your back or neck pain due to a traumatic injury such as a motor vehicle crash or fall? *

Is your back or neck pain due to a traumatic injury Status

Spine injuries such as sprains and fractures can cause either short-lived or chronic pain.

Is your back or neck pain due to a work related injury?*

Is your back or neck pain due to a work related injury status

Have you had any recent or major spine surgery? *

Have you had any recent or major spine surgery status

Depending on the diagnosis, surgery may either be the first treatment of choice—although this is rare—or it is reserved for chronic back pain for which other treatments have failed.

Do you have a primary care physician? *

Do you have a primary care physician status

In order to better serve our community, would you please let us know how you heard about this assessment? *

please let us know how you heard about this assessment status

Your Result :

Weight

Back Pain

Heavy Lifting

Neck Pain

You are almost done!

Based on your results, it sounds like you could use a little TLC, you are eligible to receive:

A free consultation with one of our board certified doctors of Chiropractic to discuss your current state of health in depth, to determine if you would be a good candidate for care at our office. Our doctors only accept those into care that they are fully confident they can help. Please note: this service is only available to select (higher-risk) individuals
A personalized report based on the answers you provided in this assessment:
Periodic health-related screening

To receive these benefits, and schedule with one of our doctors, simply click to the next page to sign-up for your complimentary consultation and start feeling and functioning better soon!

"To do nothing is actually a choice to get worse, to progress in a negative direction, meaning more pain, more degeneration, more wear and tear on the body, choose change, choose health, choose to live the life you deserve" ~Dr. James Ide

Please fill out the information below.

First Name

Middle Name

Last Name

Birth Date

Gender

Phone Number

Email Address

Address1

Address2

City

State

Zip Code

Call Us Today 810-207-6216

404 Rounds Dr. Fenton, MI 48430

Painless Chiropractic of Fenton's: Back Pain Risk Assessment

Note from our Fenton Chiropractor:

Are you a Painless DC Employee? *

Please read the following disclaimer and indicate below if you agree to all terms: *

What is your ethnic origin? (optional)

What is your height? *

What is your weight? *

Have you unexpectedly lost or gained weight in the past year? *

Do you use tobacco products or smoke cigarettes? *

Do you currently have pain, discomfort, or stiffness in your back? *

Is your pain worse in your legs or back? *

Has your back pain spread down your leg(s) at some time in the last 2 weeks? *

Have you had pain in the shoulder or neck at some time in the last 2 weeks? *

Have you only been able to walk a short distance because of your back pain? *

In the last 2 weeks, have you had to dress more slowly than usual because of back pain? *

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

Which of the following best describes your ability to lift heavy objects/weights? *

Are these symptoms worse after a period of inactivity such as getting out of bed in the morning, riding in a car for long distances, sitting in a movie theater or at a sporting event? *

Do you take prescription or over the counter medication for relief of your back pain? *

Is your back or neck pain due to a traumatic injury such as a motor vehicle crash or fall? *

Is your back or neck pain due to a work related injury?*

Have you had any recent or major spine surgery? *

Do you have a primary care physician? *

In order to better serve our community, would you please let us know how you heard about this assessment? *

Your Result :

Weight

Back Pain

Heavy Lifting

Neck Pain

Please fill out the information below.

Call Us Today 810-207-6216

404 Rounds Dr. Fenton, MI 48430

NEW PATIENTS RECEIVE FREE CONSULTATION.

Schedule Now Using this Form or Call Us at (810) 214-0684 to Take Advantage of this Special Offer.

Painless Chiropractic of Fenton's: Back Pain Risk Assessment

Note from our Fenton Chiropractor:

Are you a Painless DC Employee? *