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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.
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