Survey Page

64 Baker Street

Guelph

(548) 490-3382

Thanks For Requesting An Appointment!

Look out for call or text to confirm your requested time is available

Fill Survey Below

For us to best prepare for your appointment, please complete the brief survey below:

On a scale of 1-10, one being no pain and ten being excruciating, how would you rate your pain?

Where is the source of your pain? Choose all options that apply.

Neck

Back

Knee

Shoulder

Arms

Legs

Headache

Other

Which Health Professionals have you seen already?

Chiropractor

Physiotherapy

Massage Therapist

Family Doctor

Specialist

Others/None

How did the pain begin? Choose all options that apply.

Accident at home

Vehicle accident

Accident at work/work related

It just began

After surgery

Came on gradually

Sports related

Other

What areas of your life are affected by the pain? Choose all options that apply.

Maintaining a safe environment

Communication

Breathing

Eating & drinking

Washing & dressing

Mobilization

Working & playing

Expressing sexuality

Sleeping

Daily parenting

Finances

Household chores

Self worth/value

Physical well-being

Emotional health

Other

How committed are you to fixing your pain TODAY?

Very committed

Very committed
Somewhat committed
Neutral
Not ready to commit yet
No elements found. Consider changing the search query.
List is empty.

PLEASE ACKNOWLEDGE THE FOLLOWING STATEMENT: I will NOT miss my appointment once it is scheduled and confirmed because I respect your time and I understand it's not fair to others who would schedule in my place if I don't show up.

Yes

PLEASE ACKNOWLEDGE THE FOLLOWING STATEMENT: I am serious about my health and I will use my voucher before it expires in 30 days.

Yes