Assessment | Family First Chiropractic & Wellness | Winnipeg, MB

204.254.1313
589 St Anne's Rd.
Winnipeg, MB. R2M 5A9
info@entertogetwell.ca

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Winnipeg Chiropractors Dr.'s Jason and Danella Whittaker

1. In general, would you say your health is:
ExcellentVery GoodGoodFairPoor

2. Compared to one year ago, how would you rate your health in general now?
Much Better NowSomewhat Better NowAbout The SameSomewhat Worse NowMuch Worse Now

Typical Day Activities

The following items are about activities you might do during a typical day.
Does your health now limit you in these activities? If so how much.

3. Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports.
Limited a LotLimited a LittleNot Limited At All

4. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf.
Limited a LotLimited a LittleNot Limited At All

5. Lifting or carrying groceries.
Limited a LotLimited a LittleNot Limited At All

6. Climbing several flights of stairs.
Limited a LotLimited a LittleNot Limited At All

7. Climbing one flight of stairs.
Limited a LotLimited a LittleNot Limited At All

8. Bending, kneeling, or stooping.
Limited a LotLimited a LittleNot Limited At All

9. Walking more than a mile.
Limited a LotLimited a LittleNot Limited At All

10. Walking several blocks.
Limited a LotLimited a LittleNot Limited At All

11. Walking one block.
Limited a LotLimited a LittleNot Limited At All

12. Bathing or dressing yourself.
Limited a LotLimited a LittleNot Limited At All

How has your health affected your daily routine?

During the past 4 weeks, have you had any of the following problems with work or other regular daily activities,
as a result of your physical health?

13. Cut down the amount of time you spent on work or other activities
YesNo

14. Accomplished less than you would like.
YesNo

15. Were limited in the kind of work or other activites.
YesNo

16. Had difficulty performing the work or other activities (for example, it took extra effort).
YesNo

Living with Pain

The following items are how much pain you experience in a typical day.

17. How much pain have you had during the past 4 weeks?
NoneVery MildMildModerateSeveresVery Severe

18. During the past 4 weeks, how much did pain interfere with your normal work?
Not At AllA Little BitModeratelyQuite a BitExtremely

Your Emotional Health

The following items are about your emotional health.

19. Did you feel full of energy?
All of the timeMost of the timeA good bit of the timeSome of the timeA Little of the timeNone of the time

20. Have you been a very nervous person?
All of the timeMost of the timeA good bit of the timeSome of the timeA little of the timeNone of the time

21. Have you felt so down in the dumps that nothing could cheer you up?
All of the timeMost of the timeA good bit of the timeSome of the timeA little of the timeNone of the time

22. Have you felt calm and peaceful?
All of the timeMost of the timeA good bit of the timeSome of the timeA little of the timeNone of the time

24. Have you felt downhearted and blue?
All of the timeMost of the timeA good bit of the timeSome of the timeA little of the timeNone of the time

25. Did you feel worn out?
All of the timeMost of the timeA good bit of the timeSome of the timeA little of the timeNone of the time

26. Have you been a happy person?
All of the timeMost of the timeA good bit of the timeSome of the timeA little of the timeNone of the time

27. Did you feel tired?
All of the timeMost of the timeA good bit of the timeSome of the timeA little of the timeNone of the time

28. How often have your health problems interfered with your social activities?
All of the timeMost of the timeA good bit of the timeSome of the timeA little of the timeNone of the time

Final Health Questions

Answer these final questions about your health as honestly as possible.

29. I seem to get sick a little easier than other people
Definitely TrueMostly TrueDon't knowMostly FalseDefinitely False

30. I am as healthy as anybody I know
Definitely TrueMostly TrueDon't knowMostly FalseDefinitely False

31. I expect my health to get worse
Definitely TrueMostly TrueDon't knowMostly FalseDefinitely False

32. My health is excellent
Definitely TrueMostly TrueDon't knowMostly FalseDefinitely False

Home
Winnipeg Chiropractic
About Family First
New Chiropractic Patients
How Do We Help
Total Health and Wellness
Total Family Care
Contact
Chiropractic Articles
Client Corner
Links

The Winnipeg Chiropractors at Family First Chiropractic & Wellness Center. 589 St Anne's Rd. Winnipeg, Mb. R2M 5A9. (204)254-1313. Copyright 2006 All Rights Reserved. Sign In