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Information Request
Health & Wellness Survey
Please fill out the form below. Asterisk (
*
) denotes required field
*
Nearest location:
Ashland, KY
Chesapeake, OH
Huntington, WV
Grayson, KY
Date of survey:
*
First name:
*
Last name:
DOB:
*
Address:
Apt:
*
City:
*
State:
*
Zip:
Occupation:
Gender
M
F
Marital Status:
Single
Married
Divorced
Widow
Seperated
Children:
0
1
2
3
4
5
*
Phone Number:
Best Time to Call:
Morning
Afternoon
E-mail Address:
Do you have health insurance?
Yes
No
Do you have any of these symptoms?
Headaches
Headaches Type
Migraines
Cluster
Tension
Ringing in ears
Dizziness
Pain when chewing
Neck pain
Back pain
Back pain Type
Upper
Lower
Middle
Numbness in legs and feet
Numbness in arms and hands
Loss of balance
Joint stiffness and/or pain
Fatigue
Stress
Difficulty going to sleep
Difficulty staying asleep
Shortness of breath
Digestive problems
Foot problems
Other:
Do you have any medical considerations?
Arthritis
High Cholesterol
High Blood Pressure
Diabetes
Other:
Are you currently taking medications?
Yes
No
How many hours of sleep do you get per night?
4
5
6
7
8
9
10
How many 8 oz. glasses of water do you drink daily:
0
1
2
3
4
5
6
7
8
What is your current Health & Wellness level?
(1=Very Good – 5=Very Bad)
Eat healthy, balanced meals:
1
2
3
4
5
Consider calories when making food choices:
1
2
3
4
5
Physically active (outside of work):
1
2
3
4
5
Train with weights:
1
2
3
4
5
What is your current interest level?
(0=None – 5=High)
Chiropractic care:
0
1
2
3
4
5
Massage therapy:
0
1
2
3
4
5
Nutritional support:
0
1
2
3
4
5
Losing weight or inches:
0
1
2
3
4
5
Free gym/workout facility:
0
1
2
3
4
5
Vitamins/Supplements:
0
1
2
3
4
5
Before submitting this form, please ensure that all of the information provided above is accurate.
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