Please answer the following questions to help you learn more about your health and if chiropractic might help you. Click 'submit' when you are finished. You will receive an email from me to discuss your answers and to see if you'd like to receive a free adjustment in my practice. Thank you!

Name *
Name
Age *
Please tick your age range
1. Your mother told you that your birth was traumatic, or you were a c-section baby.
2. When you were a child you had poor coordination and didn't like athletics.
3. You were fed mostly formula as an infant.
4. You worry a lot and often have anxiety.
5. As a child, you had a lot of sudden emotional outbursts.
6. When you were a child, you were more of a logical thinker and you are analytical.
7. You tend to have a lot of allergies.
8. You tend to have digestive problems like constipation, or diarrhea, bloatedness, and stomach pains.
9. You have tense shoulders and frequent neck pain, especially when you're stressed.
10. You chronically don't sleep well.
11. Your fine motor skills, like handwriting or buttoning a shirt has been weak, especially as a child.
12. You sit at a desk all day at work and your know your posture is not good.
13. As a child, you often had ear infections.
14. You often have 'brain fog' for no reason.
15. You have been in a car accident in the past, even a fender-bender.
16. You're always tired with very low energy to keep you going through the day.
17. You have recurrent headaches and you need to pop pain pills often just to help you focus.
18. When you were a child, you made decisions based on your sense of things and your feelings, rather than logic and analysis.
19. You get severe coughs every year and you often take antibiotics to get rid of your symptoms.
20. You're sick and tired of feeling like crap.