Health Evaluation
Monitor Your Health Under Chiropractic Care
 
 
 

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Please find below our Initial & Follow-up Health Evaluation Forms

Printable Versions:

Health Evaluation ~ Initial  

Health Evaluation ~ Follow-up

Initial Health Evaluation                                    Date_______

Please score yourself from 1 to 10 below in each health category and then indicate if you are interested in receiving help in these areas. You can select as many or as few as you like.

Neck pain: 1 2 3 4 5 6 7 8 9 10 (1 no pain at all, 10 extreme pain)

I would like help and/or info on decreasing my neck pain: Yes No

Mid-back/rib cage pain: 1 2 3 4 5 6 7 8 9 10 (1 no pain at all, 10 extreme pain)

I'd like help and/or info on decreasing my mid-back/rib cage pain: Yes No

Low back pain: 1 2 3 4 5 6 7 8 9 10 (1 no pain at all, 10 extreme pain)

I would like help and/or info on decreasing my low back pain: Yes No

Shoulder pain: 1 2 3 4 5 6 7 8 9 10 (1 no pain at all, 10 extreme pain)

I would like help and/or info on decreasing my shoulder pain: Yes No

Elbow pain: 1 2 3 4 5 6 7 8 9 10 (1 no pain at all, 10 extreme pain)

I would like help and/or info on decreasing my elbow pain: Yes No

Wrist/hand pain: 1 2 3 4 5 6 7 8 9 10 (1 no pain at all, 10 extreme pain)

I would like help and/or info on decreasing my wrist/hand pain: Yes No

SI joint pain: 1 2 3 4 5 6 7 8 9 10 (1 no pain at all, 10 extreme pain)

I would like help and/or info on decreasing my SI joint pain: Yes No

Hip joint pain: 1 2 3 4 5 6 7 8 9 10 (1 no pain at all, 10 extreme pain)

I would like help and/or info on decreasing my hip joint pain: Yes No

Knee pain: 1 2 3 4 5 6 7 8 9 10 (1 no pain at all, 10 extreme pain)

I would like help and/or info on decreasing my knee pain: Yes No

Ankle/foot pain: 1 2 3 4 5 6 7 8 9 10 (1 no pain at all, 10 extreme pain)

I would like help and/or info on decreasing my ankle/foot pain: Yes No

Energy level: 1 2 3 4 5 6 7 8 9 10 (1 low energy, 10 high energy)

I would like help and/or info on increasing my energy level: Yes No

Diet and nutrition: 1 2 3 4 5 6 7 8 9 10 (1 horrible diet, 10 excellent diet)

I would like help and/or info on improving my diet and nutrition: Yes No

Exercise program: 1 2 3 4 5 6 7 8 9 10 (1 horrible exercise habits, 10 excellent exercise habits)

I would like help and/or info on exercise: Yes No

Ability to sleep well: 1 2 3 4 5 6 7 8 9 10 (1 horrible sleeper, 10 excellent sleeper)

I would like help and/or info on getting a good nightís sleep: Yes No

Stress level: 1 2 3 4 5 6 7 8 9 10 (1 no stress at all, 10 extreme stress)

I would like help and/or info on decreasing my stress: Yes No

Headache frequency: 1 2 3 4 5 6 7 8 9 10 (1 constant headaches, 10 never)

I would like help and/or info on decreasing my headaches: Yes No

Posture: 1 2 3 4 5 6 7 8 9 10 (1 poor posture, 10 perfect posture)

I would like help and/or info on improving my posture: Yes No

Breathing: 1 2 3 4 5 6 7 8 9 10 (1 poor breather, 10 good breather)

I would like help and/or info on improving my breathing: Yes No

Blood pressure: 1 2 3 4 5 6 7 8 9 10 (1 poor blood pressure, 10 normal blood pressure)

I would like help and/or info on improving blood pressure: Yes No

Daily Activities: 1 2 3 4 5 6 7 8 9 10 (1 unable to perform, 10 able to perform)

(ex: house chores, driving distance, sitting extended period, etc)

I would like help and/or info on improving my ability to perform daily activities: Yes No

Enjoyable Activities: 1 2 3 4 5 6 7 8 9 10 (1 unable to perform, 10 able to perform)

(ex: golf, gardening, play with kids)

I would like help and/or info on improving my ability to perform enjoyable activities: Yes No

Please list 5 activities of daily living you canít perform at 100% (ex: house chores, driving distance, sitting extended period, etc)

1.

2.

3.

4.

5.

Please list 5 activities you really enjoy that you canít perform at 100% (ex: golf, gardening, play with kids)

1.

2.

3.

4.

5.

 

Follow-up Health Evaluation                                       Date_______

Please circle Increased/Decreased or Improved/Worsened in each health category and write in by what percent.

Neck pain:                              Increased or Decreased by _____%

Mid-back/rib cage pain:         Increased or Decreased by _____%

Low back pain:                       Increased or Decreased by _____%

Shoulder pain:                        Increased or Decreased by _____%

Elbow pain:                            Increased or Decreased by _____%

Wrist/hand pain:                    Increased or Decreased by _____%

SI joint pain:                          Increased or Decreased by _____%

Hip joint pain:                        Increased or Decreased by _____%

Knee pain:                             Increased or Decreased by _____%

Ankle/foot pain:                      Increased or Decreased by _____%

Energy level:                          Increased or Decreased by _____%

Diet and nutrition:                  Improved or Worsened by _____%

Exercise program:                 Improved or Worsened by _____%

Ability to sleep well:               Improved or Worsened by _____%

Stress level:                             Increased or Decreased by _____%

Headache frequency:             Increased or Decreased by _____%

Posture:                                  Improved or Worsened by _____%

Breathing ability:                   Improved or Worsened by _____%

Blood pressure:                    Increased or Decreased by _____%

Score the activities of daily living that you put on your initial health form by % Improved or Worsened.

1.

2.

3.

4.

5.

Score the activities you really enjoy that you put on your initial health form by % Improved or Worsened.

1.

2.

3.

4.

5.

 

 
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