Spinal Trauma Questionnaire

Yes No   1. Have you ever fallen on your back?

Yes No   2. Have fallen from a ladder onto your back?

Yes No   3. Have you ever been hit with a heavy object in your back?

Yes No   4. Have you ever fallen and injured you neck?

Yes No   5. Have you ever fallen water skiing?

Yes No   6. Have you ever fallen snow skiing?

Yes No   7. Have you ever fallen on ice skates?

Yes No   8. Have you ever played basketball?

Yes No   9. Have you ever played football?

Yes No 10. Have you ever played Soccer?

Yes No 11. Have you ever had a diving accident?

Yes No 12. Have you ever done weight lifting and injured you back?

Yes No 13. Have you ever done weight lifting and injured your rib cage?

Yes No 14. Have you ever played hockey?

Yes No 15. Have you ever been involved in martial arts? 

Yes No 16. Have you ever fallen down a stairs?

Yes No 17. Have you ever jump off a place greater than ten feet high landing
                  on your feet?

Yes No 18. Has you head ever been compressed in fall or accident?

Yes No 19. Have you ever fallen out of a tree?

Yes No 20. Have you ever fallen out of a bunk bed?

Yes No 21. Did you ever fall while being a majorette?

Yes No 22. Did you ever fall doing gymnastics?

Yes No 23. Did you ever fall while riding a horse?

Yes No 24. Did you ever fall out of a golf cart while it was moving?

Yes No 25. Did you ever fall off a moving vehicle?

Yes No 26. Did you ever fall off a motorcycle?

Yes No 27. Have you ever fallen while running?

Yes No 28. Have you ever strained yourself lifting something too heavy? 

Yes No 29. Have you broken a bone in your spine?

Yes No 30. Have you ever had a disc injury to your spine?

Yes No   31. Have you ever had back surgery?

Yes No   32. Have you ever had a spinal block?

Yes No   33. Have you ever had a cortisone shot for back pain?

Yes No   34. Have you ever taken pain medication for back pain?

Yes No   35. Have you ever your low back weight lifting?

Yes No   36. Have you ever injured your shoulder weight lifting?

Yes No   37. Have you ever injured your wrists weight lifting?

Yes No   38. Have you ever fallen of the roof of a house or building?

Yes No   39. Have you ever jump or dove off the side of a bridge into the
                   water?

Yes No   40. Have you ever been in a pool with someone on your shoulder fall
                   forcing your neck forward?

If you answer "YES" to more than eight questions, you have tendencies toward  spinal misalignments, spinal injuries or trauma.  These patterns on injury link to other systems in the body creating a network of deeper layers and causes. These causes link to prior injuries, poor digestive patterns, cranial injuries, spinal injuries, hidden disc's injuries in the neck and upper back,  glandular disturbances,  and early primitive reflexes from early childhood, embryonic reflexes before birth.  

 After taking the test above, send the results to us with the information below. We'll get back to you by E-mail within a week. We will give you an overview and a new perspective of what can be done. Or you can call our office for an appointment and consultation. 706-379-1225

To clarify this see spine trauma, frozen shoulder, functional endocrinology,  head injury,  car accident trauma or you may which to evaluate yourself with other self tests.

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