Franhill Chiropractic

Dr. Miguel F. Martinez, DC

Backpack Questionaire

First Name:
Last Name:
BDate:
Age:
Address:
City:
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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

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