Lake Stevens Free Health Assessment Quiz: Castle Chiropractic

CASTLE CHIROPRACTIC INSTANT HEALTH ASSESSMENT FORM

Be sure you answer all of the questions before submitting your form. When your are done, press the "Submit" button at the bottom. Your scores will be tallied and you will be given your score as well as an indication of what it means in terms of your health.

NOTE: This form is not a diagnosis or a professional evaluation, but a simple self-assessment tool. Use it in order to gain a better understanding of how you are managing your health.

This assessment is for your use only. No one else will ever see the results. Enjoy!

1. Within the course of a day, I am aware of my body having one or more annoying or painful symptoms.

2. I have contacted a medical professional about a health problem within the past---

3. I have had my spinal health evaluated by a Doctor of Chiropractic within the past year.

4. When I was a child, my parents took me to a Chiropractor.

5. I pop bones in my back or neck.

6. I exercise properly.

7. I am 20 pounds overweight or more

8.I am 20 pounds underweight or more

9. I take over the counter pain relievers:

10. I take other over the counter medications

11. I get colds and/or sinus infections

12. I feel like I'm very tired

13. There is a history of major health problems in my family (heart, stroke, diabetes, disease, etc)

14. There is a history of spinal problems in my family

15. I have a tingling sensation in my hands, arms, legs which occurs:

16. I get some kind of headache

17. I feel mentally alert

18. I feel very energetic

19. If 1 were excellent and 10 were poor, I would grade my own health as:

When you are satisfied that you have answered the questions as honestly as possible, press the button below.

Castle Chiropractic
Dr. Darlene Castle
1616 83rd Ave. SE, Everett WA
(425) 334-9199 FAX: (425) 397-0117