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Take This Quiz To Find Out If You Could Be Subluxated!
1.
First Name
2.
Last Name
3.
Best Contact Number
4.
Email Address
5.
Your Health Concerns
Please tick the complaints below you are currently experiencing or have experienced in the past 12 months
Back Pain
Tension Across top of Shoulders
Nervousness
Pain between Shoulders
Neck Pain
Difficulty Sleeping
Numbing/Tingling in Arms or Hands
Allergies
Dizziness
Tension/Migraine Headaches
Ringing in Ears/Ear Infections
Low Back Pain
Sciatic Pain
Digestive Problems
Weight Trouble
6.
Which of the above conditions bothers you the most?
And how long have you been suffering this for?
7.
Does it cause you to be:
Moody
Irritable
Sleepless
Restricted on Daily Activities
8.
Does this Affect your Work:
Decision Making
Poor Attitude
Decreased Productivity
Exhausted at End of Day
Pain during the Work Day
9.
Does this affect your Life:
Lose patience with Spouse or Children
Hinders Ability to Exercise or Play Sports
Restrict Household duties
Interferes with ability to participate in Hobbies or other Desired Activities
10.
If it was possible, would you like to get to the cause of the problem?
Yes
No
11.
If your answer is yes, there are two alternatives available to you.
Please tick the item most appropriate for you:
I would like to come into the Chiropractor’s office for a complete evaluation for only $35, normally $210.
I would like to come to a class on Stress & Wellness
Thank you for taking time to think about your health. Please click SUBMIT to finish your test, one of our friendly team will be in touch with you to see how we can help.
Copyright © Body Brilliant Chiropractic Carrara, QLD
contactus@bodybrilliantchiropractic.com
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