Level One Questionnaire
Answer all questions in reference to when you first began care in this office, or to your last full re-evaluation, if applicable.
1). I am (more, same, less) aware of my spine. This awareness is especially noticeable (at work, at rest, standing, sitting, walking, moving).
2). This awareness (is, is not) a result of greater discomfort or pain.
3). (If the answer to #2 is yes) I am (aware, not aware) of what positions or movements of the spine bring about this awareness. They are: ________________________________________
4). I am ( aware, not aware ) of spinal tension and restricted movement independent of pain during my day.
5). I am ( aware, not aware ) of an increase in pleasant sensations in my spine. These are: ________________________________________
6). I am ( aware, not aware ) of changes in the way I carry my body. They are: ________________________________________
7). I am ( more, same, less ) aware of my breathing when I am adjusted.
8). I am (more, same, less) aware of my breathing in between adjusting sessions.
9). In general, my breathing is (deeper, same, more shallow) and (easier, same, more difficult).
10). In general, movement is (easier, same, more difficult).
11). In general, I (feel, do not feel) greater ease standing straighter.
12). In general, I (feel, do not feel) my spine or areas of my spine to be more at peace.
13). I am (more aware, same, less aware) of where I hold tension in my body or spine.
14). I am (more aware, same, less aware) of when my body holds tension.
15). I am (more aware, same, less aware) of what releases tension from my body.
16). My body is becoming (more effective, same, less effective) at releasing its tension.
17). I (have, have not) experienced spontaneous movements of a part of my spine when another region was adjusted.
18). I (have, have not) experienced my body trying to unwind its tension while being adjusted.
19). I (have, have not) experienced a deeper awareness of knowing exactly what my body wants me to do. This has come in the area of (rest, exercise, sleep, movement).
20). I (have, have not) been more able to listen to my body’s needs.
21). I have experienced the following additional marked mental, emotional, chemical, and physical stresses during this period, in addition to those I listed on the last questionnaire I filled out: ________________________________________
22). I have had the following major relationship, job, residence, or other life changes during this period: ________________________________________
23). I (have, have not) changed my dietary habits. Explain: ________________________________________
24) I (have, have not) begun or modified an exercise program. Explain: ________________________________________
25). I ( have, have not ) participated in classes or programs to enhance my healing capacity. Explain: ________________________________________
26) Use this space to write about anything else you would like to discuss with your chiropractor about your spinal progress at this point in care. ____________________________________________________________________________________________________
27). Do you wish to continue care at this time? ________________________________________