Greenspan Chiropractic Asheville

Fitness People

Western North Carolina
Health Survey

Thank you in advance for completing our health survey. After you submit the brief form below, you will receive a printable coupon for a complimentary chiropractic exam. If you have children you may want to also fill out our Children's Survey.

We respect your privacy. This information is only for review by Dr. Greenspan.

Name:
E-mail: (required)
Address:
City:
State:
Zip:
Home Phone:
Age:
Occupation:
Number of Children:
How did you hear about us?

Do you have trouble relaxing or falling asleep?	Yes No
Are you exhausted at the end of the day?	Yes No
Do you have weight problems?	Yes No
if so, are you Underweight?	Yes No
Overweight?	Yes No
Do you take pain relievers, antacid, tranquilizers, or any other relief oriented medicine?	Yes No
Do you exercise less than two times weekly?	Yes No
Do you feel you are a nervous or tense person?	Yes No
Do you lose your temper or become angry easily?	Yes No
Do you rely on caffeine or sugar stimulants?	Yes No
Have you ever had an auto accident or been injured on the job?	Yes No
Do any members of your immediate family have back and/or neck problems?	Yes No
Do you have any other health problems of which you are aware?	Yes No
If yes, explain,

***Please mark any and all areas of pain and/or discomfort for the items below.***
	Past	Present
Low Back Pain
Leg Pain
Neck Pain
Shoulder and Arm Pain
Disc Problems
Whiplash Neck Injuries
Arthritis
Pinched Nerve
Headache
Scoliosis
Dizziness
Numbness or Tingling in Arms or Legs
Menstrual Pain
Sinus or Allergies

Do we have permission to call you about your survey? (WNC residents only)	YesNo
Phone Number
If you live outside Western North Carolina, would you like us to put you in touch with a chiropractor in your area?	YesNo N/A

Western North Carolina Health Survey

Western North Carolina
Health Survey