Progress Check: Evaluating Your Health

Step 1 of 5 - Personal Information

DISCLAIMER:*
- I have read and agree to the disclaimer
Disclaimer: This form takes approximately 15 minutes to complete. Please ensure that when you have the time to do so, you take the time to read and answer every question; including as many details as possible. THIS IS DONE FOR YOUR OWN SAFETY as our clinic assesses every patient according to their individual needs and uses different techniques and tools to do so!
Name*
First Last
Email

Do you feel that you have given chiropractic the fullest opportunity to help you so far?*
- YES
- NO
Are you pleased with your chiropractic care thus far?*
- YES
- NO
How can we improve your care, so you can reach maximum benefit?
Are there any additional things you have noticed?

The three goals of care are:
1. Relief Care - To relieve the pain/symptoms. (Phase 1)
2. Corrective Care - To correct the cause of the pain/problem and strengthen your body in its better position. (Phase 2)
3. Preventative Care - To prevent the reoccurrence of pain and to increase overall wellness. This care will catch problems before you have to experience symptoms as injuries occur in day to day life. (Phase 3)
Which phase do you presently feel you are in?*
Are you confused or concerned about any phase of your progress?*
- YES
- NO
Please explain your confusion or concerns.*
Do you have any questions about your progress or condition?*
- YES
- NO
Please leave your question(s) and we will be sure to address them.
Have you referred anyone to Chiropractic?*
- YES
- NO
If you have referred a patient, what were their conditions or symptoms?*
Email
This field is for validation purposes and should be left unchanged.

Progress Check Appointment

Please bring a pair of shorts and a T-shirt to this appointment. This appointment will reassess your condition from your initial visit until now, and normally does not include x-rays or foot scan information.

This appointment is 30 minutes and your regular chiropractic treatment will follow directly after the progress check.

Progress Check Report

Differences between your initial exam and this progress check will be discussed with Keri-Lyn at your next appointment. This appointment takes approximately 30 minutes. Following the appointment, you will see Dr. Rodwin for your treatment.

Progress Check: Evaluating Your Health

Progress Check: Evaluating Your Health

Step 1 of 5 - Personal Information

Please answer Yes or No and/or explain where applicable.

Please rate the changes you have noticed since beginning chiropractic.

The three goals of care are:

Progress Check Appointment

Progress Check Report

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