Crawley Chiropractic Centre
Your personalised spinal health profile.
01293 320982
info@chiropractorcrawley.com
www.chiropractorcrawley.com
Your Free Spinal Health Profile
This information will be used to determine your spinal health profile.
How long do you sit on a daily basis?
All Day
Most of the day
Part of the day
Hardly, active most of the day
How often do you exercise or do activies on a weekly basis?
Never
Some days
Most days
Something every day
Have you received Chiropractic care before?
Never
Every now and then
I receive regular Chiropractic maintenance
Rate your sleep quality
Poor
Average
Excellent
Have you been in an accident or fallen from a height?
Never
Accident prone
The odd one here and there
How often do you use painkillers or other kinds of medications?
Never
Rarely
Occasionally
Every day
What do you consider your weight to be?
Underweight
Normal
Overweight
Obese
Does your weight affect any parts of your daily life?
Yes
No
Are you experiencing pain anywhere (not just the spine)? Rate your level of pain with the Red Face being "extreme pain" and the Green Face being "no pain"
Bad
OK
Good
Awesome
Do you feel your posture is poor?
Yes
No
My posture and health limit and affect my...
Work
Relationships
Daily Activities
Mental & Emotional State
Rate your average daily stress level
Minimal - I'm pretty chilled!
Pretty average
A fair amount
High stress most of the time
Please select any health issues that are bothering you
Asthma
Migraines & Headaches
Back Pain
Neck Pain
Whiplash
Sciatica
Scoliosis
Stiffness
Slipped Disc/s
Fibromyalgia
Leg Pain
Shoulder Pain
Tennis Elbow
Stomach Problems
Anxiety/Depression
Pain during pregnancy
Tendonitis
Muscular tension
Great! Enter your details to see your results.
First Name
Last Name
Email Address
Please note, your details will never be shared with anyone else.