Functional Health Management Score™ Find out if Chiropractic can help you! Answer a few simple questions, to find out if the services we offer are right for you. Step 1 of 5 20% Do you currently have a health problem or symptom that you would like addressed?*YesNoHealth Problem*Please briefly describe your current health problem.Health Goal*If you have a specific goal you would like to achieve rather than deal with any specific health problem, please briefly describe it below.What area(s) of your body are bothering you the most? (mark all that apply)** Head & Neck Eyes, Ears, Nose & Throat Upper Back Lower Back Chest & Ribs Heart Lungs Wrists & Hands Arms & Elbows Hips & Pelvis Legs & Knees Feet & Ankles Muscles & Tendons How long has the problem been going on?Place an "X" next to ONLY ONE answer that best describes you.Just started todayA few daysA few weeksA few monthsA year or longerPlease describe the frequency of your symptom(s)*Place an "X" next to ONLY ONE answer that best describes you.RareIntermittentOccasional but dailyFrequently everydayConstantPlease indicate the intensity of your symptom(s)Place an "X" next to ONLY ONE answer that best describes you.MildAnnoyingMediumGetting worseIntenseDoes your symptom(s) interfere with your daily activities?*Place an "X" next to ONLY ONE answer that best describes you.NoOnly occasionallyCan’t do certain activitiesFrequently - all activities are restrictedExtremely limited in all activitiesWhom have you seen already in an attempt to correct your health challenge or reach your health goals?*Please check all that apply. Primary Care physician Chiropractor Physical Therapist Nutritionist Medical Specialist (Orthopedist, Neurologist, Endocrinologist, etc.) I have self-treated I have done nothing at this point Please indicate the outcome from any of the above.*Place an "X" next to ONLY ONE answer that best describes you.No improvementSlight or temporary improvement25% improvement50% improvement75% improvement ELIMINATION*If you are unable to urinate or defecate please indicate how long this is going on under "Other". This could be considered a medical emergency and should be dealt with as such. 2-3 BM's per dayoften need laxatives to have a BM1 BM per day usuallyoften have diarrheatend to be constipatedDIGESTION*Place an "X" next to ONLY ONE answer that best describes you.excellent, no complaintspain, leaky gut, Crohn's, reflux, ulcers, H.pylorioccasional burping and/or intestinal gastend to get burping, heartburn, bloating, gas, indigestionstrong, frequent digestive complaintsWEIGHT*Place an "X" next to ONLY ONE answer that best describes you.at ideal weight (weight that I look and feel best)obese10 pounds overweight or underweighthard to maintain ideal weightvery hard to lose weight EXERCISE*Place an "X" next to ONLY ONE answer that best describes you.exercise every daysedentary, rarely if ever exerciseexercise 4-5 times a weekexercise 3 times a weekexercise 1-2 times a weekHow much water do you drink each day?*Place an "X" next to ONLY ONE answer that best describes you.half my body weight in ouncesI don't drink any watera gallon of watera glass of waterI get my water primarily from coffee and teaDAILY DIET*Place an "X" next to ONLY ONE answer that best describes you.little or no organic foods80-100% whole, natural organic foods60-80% whole, natural organic foodsabout 50% organic, 50% non-organicoften hungry, have cravings, or desire sweets SLEEP*Place an "X" next to ONLY ONE answer that best describes you.sleep well, 7-8 hours per nightsleep problems, sleep deprivedsleep OK, 6-7 hours usuallyfall asleep but wake up and can’t go back to sleephave trouble falling asleepENERGY*Place an "X" next to ONLY ONE answer that best describes you.have great energy through the day and eveninglow energy, fatigue, need stimulants (coffee, tea, etc.)generally have pretty good energy, could have moregood energy except afternoons, after lunchenergy goes up and down, tends to be lowIMMUNITY*Place an "X" next to ONLY ONE answer that best describes you.excellent immunity, rarely sick, get well quicklyoften sick, hard to get well, long recovery timeoccassionally sick but get well soonget sick when stressed or run downtend to catch anything that comes aroundMIND - EMOTIONS*Place an "X" next to ONLY ONE answer that best describes you.no mental or emotional complaints"brain fog" or anxious or depressed oftenmind OK but not what it was, some moodinessbad memory, forgetful, and/or up and down moodssome focus issues, sometimes anxious or depressed MOTIVATION*Rate your MOTIVATION to follow a health-building program on a scale from 1-10, with 1 being the lowest level of motivation and 10 being the highest levelPlease enter a number from 1 to 10.WILLINGNESS*Rate your WILLINGNESS to follow a health-building program on a scale from 1-10, with 1 being the lowest level of willingness and 10 being the highest levelPlease enter a number from 1 to 10.Name* First Last Email* PhoneScoreNameThis field is for validation purposes and should be left unchanged.
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