Rehabilitation Chiropractic dba Aaaah...Wellness
HEALTH QUESTIONNAIRE
Your Name
*
First Name
Middle Name
Last Name
Your Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Today's Date
*
-
Month
-
Day
Year
Date
How would you rate your energy level?
*
1
2
3
4
5
6
7
8
9
10
Low
High
1 is Low, 10 is High
What is your energy level at the highest?
*
1
2
3
4
5
6
7
8
9
10
Low
High
1 is Low, 10 is High
What is your energy level at the lowest?
*
1
2
3
4
5
6
7
8
9
10
Low
High
1 is Low, 10 is High
How many hours on average per night do you sleep?
*
2-4
4-6
6-8
8+
Do you have trouble falling asleep?
*
Yes
No
How would you rate your stress level?
*
1
2
3
4
5
6
7
8
9
10
Low
High
1 is Low, 10 is High
How would you rate your daily activity?
*
Sedentary
Lightly Active
Active
Very Active
What would you like your daily activity level to be?
*
Sedentary
Lightly Active
Active
Very Active
How would you rate your diet on average?
*
Very Poor
Poor
Average
Above Average
Healthy
What level would you like your diet to be at?
*
Very Poor
Poor
Average
Above Average
Healthy
Which of the following would you like to improve? (You may check more than one)
*
Quality of Life
Disease Prevention
Longevity
Body Recomposition
Performance
Submit
Should be Empty: