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Providence Chiropractic Clinic Rider Survey   Please indicate your gender.   Male   Female     Please indicate your age in years.     Are your stirrups set evenly?   Yes   No     If no, then which stirrup is higher up?   Right   Left   Even     How many holes higher is the shorter stirrup?   0   1   2   3   4+     Which of the symptoms below do you experience when riding? (check all that apply)   Headaches   Neck Pain   Low Back Pain   Arm and/or hand pain/numbness   Leg and/or foot pain/numbness     Which of the symptoms below do you experience even when not riding? (check all that apply)   Headaches   Neck Pain   Low Back Pain   Arm and/or hand pain/numbness   Leg and/or foot pain/numbness     Have you had your spine/pelvis checked for degrees of imbalance?   Yes   No

Please contact dr.kuhn@providencenucca.com if you have any questions regarding this survey.