Home
About Us
Our Team
Facilities and Services
Fees
Success Stories
Workshops
NutriDyn Nutritional Support
Affiliates
Chiropractic
Chiropractic
New Patients
Innate Wellness
Massage
Fitness
Innate Wellness
Functional Fitness
Special Offers
Contact Us
Home
About Us
Our Team
Facilities and Services
Fees
Success Stories
Workshops
NutriDyn Nutritional Support
Affiliates
Chiropractic
Chiropractic
New Patients
Innate Wellness
Massage
Fitness
Innate Wellness
Functional Fitness
Special Offers
Contact Us
Progress REVIEW FORM 2
Please help us to serve you better by responding to the following questions about your progress.
Name
*
First Name
Last Name
Review Consent
*
I hereby give consent to undergo a chiropractic review, evaluation and/or posture image.
1. Would you consider writing us a review?
2. What changes have you noticed since beginning Chiropractic care?
3. On a scale of one to ten, rate the level of your overall improvement so far:
No Change
1
2
3
4
5
6
7
8
9
10
Major Change
4. How do you find your Chiropractic adjustments help you?
5. What other improvements have you noticed in your general health?
6. How many days per week do you exercise?
7. How would you rate the care, concern and efficiency shown by our team?
Very Poor
1
2
3
4
5
6
7
8
9
10
Great
8. Are you happy with your overall care at this stage?
9. Please tick if you are experiencing any of the following:
Increased energy
More balanced
Feeling stronger
Feeling more alert
Able to relax better
Better concentration
10. Please tick if any of the following activities are easier:
Sleeping
Walking
Driving
Sitting
Standing
Working
Bending/Lifting
Sports
11. Would you like to continue with care? If yes, How often do you feel you should be adjusted?
12. Is there anyone you would like a New Patient voucher for?
I am happy for my feedback and pictures to be used in office, on our social media and/or website:
*
Yes
No
On-going Consent
*
A Chiropractic adjustment is considered to be a safe and effective form of therapy for spinal conditions, i.e. vertebral subluxation. A re-evaluation has been performed. If you have any questions about this, please ask your chiropractor.
I have read the above statement and therefore consent to ongoing spinal adjustive Chiropractic treatment.
Date
*
MM
DD
YYYY
Thank you!