Chiari Wellness Evaluation

All fields with an asterisk (*) are required.

Thank You

The form was submitted successfully.

2022-CONT-Medical Center of Aurora-Chiari Wellness Evaluation-PHI
Date of Birth*

Sleep Patterns

Do you have difficulty getting to sleep?*
Why do you wake up? (Mark all that apply)
Do you rest during the day?*
Do you ever feel rested when you wake up?*
What helps you sleep better? (Mark all that apply)
Do you use medications to sleep?*
Have you ever tried medications that have not worked?*

Nutritional Habits and Fitness Limitations

If less than three, why?
Do you snack?*
Do you eat fast food?*
Do you drink caffeinated beverages? *
Are you familiar with different food groups?*
Overall, do you think you are a healthy eater?*
Do you take vitamins or other supplements routinely?*
Is your schedule flexible?
Have you had an ergonomic evaluation (correct sitting/standing guidelines)*
Are you on disability?*
Do you participate in any scheduled exercise (work out/aerobics)?*
Are you able to do household chores? *
If yes, what chores can you complete? (mark all that apply)


Do you drink alcohol? *
Do you use medical marijuana?*
Do you use recreational drugs to treat your pain?*
Do you use tobacco products?*
Have you been prescribed pain medication?*
Do you live alone?*
Do you have family who understands your condition? *

Over the last 2 weeks, how often have you been bothered by any of the following problems?

Little interest or pleasure in doing things.*
Feeling down, depressed, or hopeless.*
Trouble falling or staying asleep, or sleeping too much.*
Feeling tired or having little energy. *
Poor appetite or overeating.*
Feeling bad about yourself — or that you are a failure or have let yourself or your family down.*
Trouble concentrating on things, such as reading the newspaper or watching television.*
Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual. *
Thoughts that you would be better off dead or of hurting yourself in some way.*
If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?*