Skip to content

Home
About
Our People
Free Balance Check
Services
Contact

Home
About
Our People
Free Balance Check
Services
Contact

A-Noone CSI

Central Sensitization Inventory

Please Complete this questionnaire and submit it. All answers should be relevant to the PAST MONTH.

The questionnaire takes approximately FIVE MINUTES to complete.

PART A of the questionnaire consists of 25 questions.

Please click on the answer to each question where you will find FIVE possible options.

Please choose ONE.

PART B of the questionnaire requires you to tick any box that indicates a previous diagnosis made by a health practitioner.

Please tick as many boxes as necessary

The answers to this questionnaire will provide Dr Noone with important information about your nervous system.

We will discuss the results of the questionnaire at your consultation

This is an evidence-based questionnaire that has been repeated scientifically validated. It provides us with information regarding the sensitivity of your nervous system. This enables us to determine the level of treatment we should provide you.

First

Last

Date of Birth (dd/mm/yyyy)

Email *

Choose one option for each of the following questions. Answer each question as it relates to how you have been feeling in the past month

1. I feel unrefreshed when I wake up in the morning *

2. My muscles feel stiff and achy *

3. I have anxiety attacks *

4. I grind or clench my teeth *

5. I have problems with diarrhoea and/or constipation *

6. I need help in performing my daily activities *

7. I am sensitive to bright lights *

8. I get tired easily when I am physically active *

9. I feel pain ALL OVER my body *

10. I have headaches *

11. I have discomfort in my bladder and/or burning when I urinate *

12. I do not sleep well *

13. I have difficulty concentrating *

14. I have skin problems such as dryness, itchiness or rashes *

15. Stress makes my physical symptoms get worse *

16. I feel sad or depressed *

17. I have low energy *

18. I have tension in my neck and shoulders *

19. I have pain in my jaw *

20. Certain smells, such as perfumes make me feel dizzy and nauseated *

21. I have to urinate frequently *

22. My legs feel uncomfortable and restless when I am trying to get to sleep of a night *

23. I have difficulty remembering things *

24. I suffered trauma as a child *

25. I have pain in my pelvic area

We would now like you to complete following section. Have you ever been diagnosed with one of the following disorders? Please tick the box if you have, IF YOU HAVE NOT, THERE IS NO NEED TO TICK A BOX

CSI-Part B

Restless Legs Syndrome
Chronic Fatigue Syndrome
Fibromyalgia
Temporo-mandibular Joint Disorder
Migraine or Tension Headache
Irritable Bowel Syndrome
Multiple Chemical Sensitivities
Neck Injury (including Whiplash)
Anxiety or Panic Attacks
Depression
Persistent Postural-Perceptual Dizziness

Email *

Name

Call Us: 0395987787
Email Us: smallstreetchiro@gmail.com

Services

Spine-Related Balance Disorders
Complex Care Chiropractic Services
Chiropractic Services
Free Balance Check

Our People

Paul Noone
Tony Cassis
Joan Noone

Business Hours

Monday: 9am-7pm
Tuesday: 9am-7pm
Wednesday: 9am-7pm
Thursday: 9am-7pm
Friday: 8am-12pm

Copyright © 2026 Small Street Clinic Hampton | Powered by Small Street Clinic Hampton