Pre-Chiropractic Survey

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I came into Maillette Family Chiropractic because of lower back pain and neck pain which I had been suffering from for years, but I just never got around to taking care of me. After just a week and a lot of questions for Dr. Maillette I decided to bring in the rest of my family as well.

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Stresses throughout your life can cause problems in your spine affecting nerves. Many of us may have experienced these stresses without knowing the long-term affects. To find out if you’re a candidate for chiropractic care please check the appropriate boxes: C (child), T (teenager), A (adult), or N (not at all)
Physical Stress
Birth Traumas (as a mother or child)	ChildTeenagerAdultNot at all Invalid Input
Slips/Falls	ChildTeenagerAdultNot at all Invalid Input
Car Accidents	ChildTeenagerAdultNot at all Invalid Input
Sports Injuries	ChildTeenagerAdultNot at all Invalid Input
Physical Abuse	ChildTeenagerAdultNot at all Invalid Input
Work Injuries	ChildTeenagerAdultNot at all Invalid Input
Poor Posture	ChildTeenagerAdultNot at all Invalid Input
Sitting on wallet for years	ChildTeenagerAdultNot at all Invalid Input
Sleeping Position – Stomach	ChildTeenagerAdultNot at all Invalid Input
Extensive Computer Work	ChildTeenagerAdultNot at all Invalid Input
Carrying heavy purse/bookbag/child	ChildTeenagerAdultNot at all Invalid Input
Repetitive Lifting/Bending	ChildTeenagerAdultNot at all Invalid Input
Driving for Many Hours	ChildTeenagerAdultNot at all Invalid Input
Continuous Hours Sitting/Standing	ChildTeenagerAdultNot at all Invalid Input
Bone Fracture/Surgery	ChildTeenagerAdultNot at all Invalid Input

Emotional Stress
Relationships	ChildTeenagerAdultNot at all Invalid Input
Career	ChildTeenagerAdultNot at all Invalid Input
Children	ChildTeenagerAdultNot at all Invalid Input
Money	ChildTeenagerAdultNot at all Invalid Input
Fast-Paced Life	ChildTeenagerAdultNot at all Invalid Input
Hold in Feelings	ChildTeenagerAdultNot at all Invalid Input
Quick tempered	ChildTeenagerAdultNot at all Invalid Input
Verbal Abuse	ChildTeenagerAdultNot at all Invalid Input
Perfectionist	ChildTeenagerAdultNot at all Invalid Input
Procrastinator	ChildTeenagerAdultNot at all Invalid Input
Sickness or Loss of Loved One	ChildTeenagerAdultNot at all Invalid Input

Chemical Stress
Environment (Example: pollution)	ChildTeenagerAdultNot at all Invalid Input
Smoker	ChildTeenagerAdultNot at all Invalid Input
Second-hand Smoke	ChildTeenagerAdultNot at all Invalid Input
Poor Diet	ChildTeenagerAdultNot at all Invalid Input
Caffeine	ChildTeenagerAdultNot at all Invalid Input
Excessive Sugar	ChildTeenagerAdultNot at all Invalid Input
Artificial Sweeteners	ChildTeenagerAdultNot at all Invalid Input
Prescription Drugs	ChildTeenagerAdultNot at all Invalid Input
Over-the-counter drugs (Example: Tylenol; Motrin)	ChildTeenagerAdultNot at all Invalid Input

Other Questions
What are you primary health concerns?	Invalid Input
What are you willing to do to become healthier? (Examples: nutrition, exercise, quit smoking)	Invalid Input
Name (*)	Invalid Input
Phone (*)	Invalid Input
Email (*)	Invalid Input
To avoid automatic submissions, please answer this captcha question	Invalid Input

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Physical Stress

Emotional Stress

Chemical Stress

Other Questions