Wellness survey
Answer the questions in the section below. Each response will be a number from 0 to 5, and will correspond to either
how strongly you agree with the statement
0= Strongly disagree 1= Disagree
2= Mildly disagree 3= Mildly agree 4=Agree 5=Strongly
Agree
General
I maintain a healthy diet (Low sugar, fresh food and whole grains
my water intake is adequate (2 litres a day)
I feel I am physically active ( recommended 150 minutes of activity a week)
I am within 20% of my ideal healthy weight
I fall asleep easily
When I wake I feel well rested
I have enough engery to meet all my daily responsibilities
I often take part in stretching exercises
I regularly schedule chiropractic, massage, Physio etc appointments to maintain my health
Total
Pain
/5
/5
/5
/5
/5
/5
/5
/5
/5
/45
TICK ANY OF THE FOLLOWING YOU HAVE EXPERIENCED IN THE PAST 6 MONTHS.
Low Back Pain
Elbow Pain
Tension Across Top of Shoulders
Shoulder Pain
Numbing/Tingling in Arms or Hands
Numbing/Tingling in Legs or Feet
Tension/Headaches
Ankle/Foot Pain
Knee pain
Pain Between Shoulder Blades
Neck Pain
Hip Pain
Arthritis
Dizziness
Tired/Fatigued
Wrist/Hand Pain
Which of the above is worse? ______________________________________________________
How long have you had it? ______________________________________________________
When it is at its worst, how does it feel? ______________________________________________________
Does this cause you to be:
Does this affect your work:
Does this affect your life:
Moody
Decision Making
Lose Patience with Spouse or Children
Irritable
Poor Attitude
Restricted Household Duties
Interrupt Sleep
Decreased Productivity
Hinders Ability to Exercise or
Restricted on Daily Activities.
Exhausted at End of Day
Participate in Sports
Unable to Work Long Hours
Interferes with Ability to Participate
in Hobbies or other Desired Activities.
You have now completed your wellness survey.
Now take a moment to reflect on your answers!
If you scored 45 on the general section congulations!!
If not how do you think you could improve your gerneral well being
Here are 5 tips to get you started
1.
Eat colourful fruits and vegetables - Getting your 5 A Day is easier than it sounds. Why not
chop a banana over your breakfast cereal, or swap your usual mid-morning snack for a piece
of fresh fruit?
2.
Get on the move, make it a habit - Physical activity is important for people of all weight
ranges and health conditions. It helps us burn off the extra calories. Why not take a walk in
your lunch break or take the stairs instead of the escalators.
3. Drinking an adequate amount of water - drinking eight to 10 glasses every day, can help
keep you hydrated. Many foods are also good sources of water; fruits like oranges, grapefruit,
grapes, watermelon, and apples can help keep you healthy and hydrated.
4. Think Positive - Research shows a healthy positive attitude helps build a healthier immune
system and boosts overall health. Your body believes what you think, so focus on the positive.
5. Stretch regularly - There are many benefits to regular stretching. Not only can stretching
help increase your flexibility, which is an important factor of fitness, but it can also improve
your posture, reduce stress, body aches, and more.
Did you check any of the boxes in the pain
section?
Would you like to get rid of the problem?
YE
S
NO
If your answer is YES, there are a few alternatives available to you. Please check the item most appropriate to
you.
I would like to come to the chiropractor’s for a complete evaluation. This will allow me to find out if
I can be helped by Chiropractic without further obligation.
I would like the Chiropractor to call me to discuss my health problems before making an appointment.
Name_______________________ Signature_____________________
Contact Number___________________ Date________________________
Clarks Chiropractic
Darwin Wellness Therapy Centre
22 Chestnut Avenue
Northwood
Email - contact@clarkschiropractic.co.uk
Middlesex
Tele - 07555135782
HA6 1HR