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  Home About Us Family Health Health Tour & Health Tests Contact Us  

Better Health Chiropractic

   
 

Dr. Jeffery G. Beavers, DC

 
 

Backpack Questionaire

First Name:
Last Name:
BDate:
Age:
Address:
City:
State:
Zip:
Phone:
Fax:
Email Address:
Yes
No
Postural Abnormalities With Back Pack Off
High Shoulder
Left
Right
Head Tilt
Left
Right
Scapula High
Left
Right
Pelvis High
Left
Right
Postural Abnormalities With Back Pack On
High Shoulder
Left
Right
Head Tilt
Left
Right
Scapula High
Left
Right
Pelvis High
Left
Right
 
 
Yes
No
With your child standing at 'Attention', shirt off, do you notice a curve in their spine when looking at their spine from behind?
Symptoms / Health Problems With Back Pack On
Headaches
Neck Pain
Muscle Pain
Tingling Hands
Low Back Pain
Activities of Daily Living That Increase / Decrease Symptoms
Sitting
Standing
Bending
Lifting
Carrying
Pushing
Pulling
Reaching
Activities of Daily Living Patient Would Like To Do, But Can't
Sports
Work-Related
Home Activities
Previous Musculoskeletal Complaints / Previous Accidents
At Home
At Work
From Sports

We do not sell or distribute your personal information to anyone other than the doctor on this website. By checking the box you agree to have your information e-mailed to the doctor so that he can evaluate the survey/test you filled out. By checking the box you also agree that you would like to have the doctor provide you with feedback as it relates to your completed survey/test.


Would you like to hear the results of your assessment and the recommendations of care via the telephone or email?
Telephone Email


 
   
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