Network Spinal Analysis: Health, Wellness and Quality of Life Questionnaire
Answer each section: place a circle around the number that best represents you now.
I.Physical State
Rate the following with respect to frequency:
  Never Rarely Occasionally Regularly Constantly
1. Presence of physical pain 1 2 3 4 5
2. Feeling of tension or stiffness or lack of flexibility in your spine. 1 2 3 4 5
3. Incidence of fatigue or low energy. 1 2 3 4 5
4. Incidence of colds and flu. 1 2 3 4 5
5. Incidence of headaches (of any kind). 1 2 3 4 5
6. Incidence of nausea or constipation. 1 2 3 4 5
7. Incidence of menstrual discomfort. 1 2 3 4 5
8. Incidence of allergies or skin rashes. 1 2 3 4 5
9. Incidence of dizziness or light-headedness. 1 2 3 4 5
10. Incidence of accidents, near accidents, falling or tripping. 1 2 3 4 5
II.Mental/Emotional State
Rate the following with respect to frequency:
  Never Rarely Occasionally Regularly Constantly
1. If pain is present, how distressed are you about it. 1 2 3 4 5
2. Presence of negative or critical feelings about yourself. 1 2 3 4 5
3. Experience of moodiness, temper or anger. 1 2 3 4 5
4. Experience of depression, lack of interest. 1 2 3 4 5
5. Being overly worried about things. 1 2 3 4 5
6. Difficulty thinking or concentrating, indecisiveness. 1 2 3 4 5
7. Experience of vague fears or anxiety. 1 2 3 4 5
8. Being fidgety, restless or difficulty “sitting still”. 1 2 3 4 5
9. Difficulty falling or staying asleep. 1 2 3 4 5
10. Experience of recurring thoughts or dreams. 1 2 3 4 5
III.Stress Evaluation
Evaluate your stress relative to the following:
  Never Slight Moderate Pronounced Extensive
1. Family 1 2 3 4 5
2. Significant relationship 1 2 3 4 5
3. Health 1 2 3 4 5
4. Finances 1 2 3 4 5
5. Sex Life 1 2 3 4 5
6. Work 1 2 3 4 5
7. School 1 2 3 4 5
8. General well-being 1 2 3 4 5
9. Emotional well-being 1 2 3 4 5
10. Coping with daily problems 1 2 3 4 5
Health, Wellness and Quality of Life Questionnaire
IV.Life Enjoyment
Rate the following on a degree scale:
  Not at all Slight Moderate Considerable Extensive
1. Openness to guidance from your “inner voice/feelings” 1 2 3 4 5
2. Experience of relaxation, ease, or well-being. 1 2 3 4 5
3. Presence of positive feelings about yourself. 1 2 3 4 5
4. Interest in maintaining a healthy lifestyle. 1 2 3 4 5
5. Feelings of being open, aware/connected when relating to others. 1 2 3 4 5
6. Level of confidence in your ability to deal with adversity. 1 2 3 4 5
7. Level of compassion for, and acceptance of, others. 1 2 3 4 5
8. Satisfaction with the level of recreation in your life. 1 2 3 4 5
9. Incidence of feelings of joy or happiness. 1 2 3 4 5
10. Level of satisfaction with your sex life 1 2 3 4 5
11. Time devoted to things you enjoy. 1 2 3 4 5
V.Overall Quality of Life
Evaluate your feelings relative to quality of life:
  Terrible Unhappy Mostly Dissatisfied Mixed Mostly Satisfied Pleased Delighted
1. Your personal life 1 2 3 4 5 6 7
2. Your spouse, partner or significant other 1 2 3 4 5 6 7
3. Your romantic life 1 2 3 4 5 6 7
4. Your job/career 1 2 3 4 5 6 7
5. Your co-workers, staff or employees 1 2 3 4 5 6 7
6. The actual work you do 1 2 3 4 5 6 7
7. The handling of problems in your life 1 2 3 4 5 6 7
8. What you are actually accomplishing in life 1 2 3 4 5 6 7
9. Your physical appearance 1 2 3 4 5 6 7
10. Your self 1 2 3 4 5 6 7
11. Your ability to adjust to change in your life 1 2 3 4 5 6 7
12. Your life as a whole 1 2 3 4 5 6 7
13. Overall contentment with your life 1 2 3 4 5 6 7
14. The extent to which your life has been as you want it 1 2 3 4 5 6 7
To be completed for Re-evaluations only
VI.Overall Impressions:
Answer each question with respect to when you first came to this office:
  Better Same Worse
1. Overall my physical well-being is 1 2 3
2. Overall my mental/emotional state is 1 2 3
3. Overall my ability to handle stress is 1 2 3
4. Overall my enjoyment of life is 1 2 3
5. Overall my quality of life is 1 2 3