Progress Check - Back to Health Wellness Centre

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- 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

Please answer Yes or No and/or explain where applicable.
In your opinion, has the general condition of your health improved?*
- YES
- NO
Which symptoms have improved?
Can you now engage in activities which were prohibited or limited by your previous condition?*
- YES
- NO
Which activities?
Have you been careful to avoid bumps, falls, and sudden shock that might re-injure your: spine, shoulder, elbow, wrist, hip, knee or feet, during the period required for re-adaptation?*
- YES
- NO
Have you followed the recommendations of this office regarding posture changes at work, sleep, rest, icing and stretching?*
- YES
- NO
Has there been any recurrence of symptoms you experienced prior to becoming a patient of this office?*
- YES
- NO
Please explain your recurring symptoms.*
Are the symptoms different in any way to those previously experienced?
Are you being treated for a concussion/s?*
Are you experiencing any of the following cognitive symptoms of a concussion?*
- Difficulty thinking clearly
- Difficulty concentrating
- Difficulty remembering new information
- Disorientation
- Temporary amnesia
- Short term memory problems
- Poor judgement
- Slow thinking
- Difficulty reading
- Difficulty with math
- Poor word recall
- Forgetting people’s names
- Poor decision making
- Lack of organization
- Longer response time
- Confusion
- Brain fog
- Forgetting previously learned skills
- Difficulty driving
- Get lost easily
- Spelling difficulty
- Poor comprehension
- Difficulty following instructions
- Difficult to think in noisy environments
- Inability to multi-task
- Poor follow through
- Difficulty with logic
- Difficulty with abstract thinking and being creative
- Difficult to watch TV, use the computer or play video games
- Loss of consciousness
- Slurred speech
- Absence seizures
- Chills
- Difficulty staying focused
- N/A
Please check all that apply.
Has the symptom "difficulty thinking clearly"...*
Has the symptom "difficulty concentrating"...*
Has the symptom "difficulty remembering new information"...*
Has the symptom "disorientation"...*
Has the symptom "temporary amnesia"...*
Has the symptom "short-term memory problems"...*
Has the symptom "poor judgement"...*
Has the symptom "slow thinking"...*
Has the symptom "difficulty reading"...*
Has the symptom "difficulty with math"...*
Has the symptom "poor word recall"...*
Has the symptom "forgetting people's names"...*
Has the symptom "poor decision making"...*
Has the symptom "lack of organization"...*
Has the symptom "longer response time"...*
Has the symptom "confusion"...*
Has the symptom "brain fog"...*
Has the symptom "forgetting previously learned skills"...*
Has the symptom "difficulty driving"...*
Has the symptom "get lost easily"...*
Has the symptom "spelling difficulty"...*
Has the symptom "poor comprehension"...*
Has the symptom "difficulty following instructions"...*
Has the symptom "difficult to think in noisy environments"...*
Has the symptom "inability to multitask"...*
Has the symptom "poor follow through"...*
Has this symptom "difficulty with logic"...*
Has this symptom "difficulty with abstract thinking and being creative"...*
Has the symptom "difficult to watch TV, use the computer or play video games"...*
Has the symptom "loss of consciousness"...*
Has the symptom "slurred speech"...*
Has the symptom "absence speech"...*
Has the symptom "chills"...*
Has the symptom "difficulty staying focused"...*
Are you experiencing any of the following physical symptoms of a concussion?*
- Headache
- Migraine
- Tension headaches
- Fuzzy or blurry vision
- Double vision
- Feeling groggy
- Nausea or vomiting
- Dizziness or lightheadedness
- Sensitivity to noise, light or touch
- Balance problems
- Fatigue
- Feeling tired
- Having no energy
- TMJ issues
- Hearing problems
- Tinnitus
- Loss of libido
- Exaggerated awareness of aches and pains
- Loss of balance
- Sense of smell or taste change
- Difficulty in swallowing
- Slowed reflexes
- Gait changes
- Co-ordination or speed of performance
- Seizures
- Pressure in the head
- Neck pain
- Strange taste in mouth
- Seeing stars
- N/A
Please select all that apply.
Has the symptom "headache"...*
Has the symptom "migraine"...*
Has the symptom "tension headaches"...*
Has the symptom "fuzzy or blurry vision"...*
Has the symptom "double vision"...*
Has the symptom "feeling groggy"...*
Has the symptom "nausea and vomiting"...*
Has the symptom "dizziness or lightheadedness"...*
Has the symptom "sensitivity to noise, light or touch"...*
Has the symptom "balance problems"...*
Has the symptom "fatigue"...*
Has the symptom "feeling tired"...*
Has the symptom "having no energy"...*
Has the symptom "TMJ issues"...*
Has the symptom "hearing problems"...*
Has the symptom "tinnitus"...*
Has the symptom "loss of libido"...*
Has the symptom "exaggerated awareness of aches and pains"...*
Has the symptom "loss of balance"...*
Has the symptom "sense or smell or taste change"...*
Has the symptom "difficulty swallowing"...*
Has the symptom "slowed reflexes"...*
Has the symptom "gait changes"...*
Has the symptom "co-ordination or speed of performance"...*
Has the symptom "seizures"...*
Has the symptom "pressure in the head"...*
Has the symptom "neck pain"...*
Has this symptom "strange taste in mouth"...*
Has the symptom "seeing stars"...*
Are you experiencing any of the following sleep related symptoms of a concussion?*
- Sleeping more than usual
- Sleeping less than usual
- Trouble falling or staying asleep
- N/A
Please select all that apply.
Has the symptom "sleeping more than usual"...*
Has the symptom "sleeping less than usual"...*
Has the symptom "trouble falling or staying asleep"...*
Are you experiencing any of the following mood/emotional symptoms of a concussion?*
- Irritability
- Sadness
- More emotional
- Nervousness or anxiety
- Depressed
- Agitation
- Apathy
- Anxiety
- Feeling of going crazy
- Frustration
- Anger
- Hostility
- Paranoia
- Guilt
- Shame
- Helplessness
- Why me
- Mood swings
- Low motivation
- Gullibility
- Easily overwhelmed
- Exaggerated response to stimuli
- Low self-esteem
- Nightmares
- Day terrors
- Mania
- Excessive excitement
- N/A
Has the symptom "irritability"...*
Has the symptom "sadness"...*
Has the symptom "more emotional"...*
Has the symptom "nervousness or anxiety"...*
Has the symptom "depressed"...*
Has the symptom "agitation"...*
Has the symptom "apathy"...*
Has this symptom "anxiety"...*
Has the symptom "feeling of going crazy"...*
Has the symptom "frustration"...*
Has the symptom "anger"...*
Has the symptom "hostility"...*
Has the symptom "paranoia"...*
Has the symptom "guilt"...*
Has the symptom "shame"...*
Has the symptom "helplessness"...*
Has the symptom "why me"...*
Has the symptom "mood swings"...*
Has the symptom "low motivation"...*
Has the symptom "gullibility"...*
Has the symptom "easily overwhelmed"...*
Has this symptom "exaggerated response to stimuli"...*
Has the symptom "low self-esteem"...*
Has the symptom "nightmares"...*
Has the symptom "day terrors"...*
Has the symptom "mania"...*
Has the symptom "excessive excitement"...*
Are you experiencing any of the following behavioural symptoms of a concussion?*
- Confrontational
- Temper tantrums
- Fearfulness
- Impatience
- Thoughtlessness
- Compulsive behaviours
- Obsessive behaviours
- Lack of social ease
- Personality changes
- Bi-polar
- Difficulty adapting to change
- N/A
Please select all that apply.
Has the symptom "confrontational"...*
Has the symptom "temper tantrums"...*
Has the symptom "fearfulness"...*
Has the symptom "impatience"...*
Has the symptom "thoughtlessness"...*
Has the symptom "compulsive behaviours"...*
Has the symptom "obsessive behaviours"...*
Has the symptom "lack of social ease"...*
Has the symptom "personality changes"...*
Has the symptom "Bi-polar"...*
Has the symptom "difficulty adapting to change"...*

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?*
Phone
This field is for validation purposes and should be left unchanged.

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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