MSK Assessment | FernCreekChiro

Fill Out Your MSK Pain Questionnaire

After submitting the MSK pain assessment, you will have the opportunity to schedule a free 20-minute discovery call to discuss your primary issues with a member of our team, as well as what next steps to take to address your chronic pain.

First Name

Last Name

Phone

Nutritional Health

I eat less than 9 servings of fruits and vegetables daily?

I get frequent colds, flus, diarrhea, constipation, bloating, heartburn?

I take any medication for pain, inflammation, diabetes, blood pressure or cholesterol?

I frequently consume refined, sugary foods, sweets and soda?

I eat grain products, white bread, pasta, cereal, chips and crackers daily?

I eat fried foods, fast foods and packaged foods daily?

I smoke or consume excess alcoholic beverages frequently?

How many nutritional health boxes did you check?

Physical Health

Exercising frequently is a challenge for me.

I have experienced physical trauma throughout my lifetime. (accidents/injury)

I have experienced pain or limitations with basic tasks (bathing, dressing, cleaning, yard work).

I have poor posture or spend 2 hours per day on a screen (phone, computer, tablet)

I have experienced tingling, numbness, or shocking sensations in the past month.

I have experienced stiffness or soreness upon waking. (Poor connective tissue function)

I lift weights less than 4 times per week or have you been told that you have decreasing bone density. (Poor muscle strength, movement patterns, muscle tone and bone density)

How many physical health boxes did you check?

Psychological Health

I struggle with falling asleep, staying asleep or oversleeping.

I feel down, depressed or have mood swings.

I feel tired, fatigued or have low energy.

I have a poor appetite, overeat or have difficulty losing weight.

I feel anxious, worried, nervous, irritable or restless.

I feel isolated from friends and family.

I struggle with focus, concentration or poor memory.

How many psychological health boxes did you check?

How many TOTAL health boxes did you check?

Select an option

0-7: You have low risk of pain and dysfunction ask your clinician about the GREEN Plan.

7-14: You have moderate risk of pain and dysfunction. Ask your clinician about the YELLOW Plan.

14-21: You have high risk of pain and dysfunction. Ask your clinician about the RED Plan.

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Discover Where Your Body Needs Extra TLC!

Take the quiz and find out which stressors are ruling your life...plus discover how to bring your chronic pain under control, naturally.

Are You Ready To Finally Ditch Your Chronic Pain?

Fill Out Your MSK Pain Questionnaire