Progress REVIEW FORM 4

Name

First Name

Last Name

Review Consent

I hereby give consent to undergo a chiropractic review, evaluation and/or posture image.

1. Please help us to serve you better by responding to the following questions about your progress. What areas of your health would you like to improve on in the future?

2. Have you had massage at HSW? Any feedback?

3. On a scale of one to ten, rate the level of improvement of your spine and health so far:

4. What changes have you noticed since having regular chiropractic care?

5. Have you made any lifestyle changes to aid your healing since beginning chiropractic care?

6. Tick if you are completing any of the following and how often?

Cervical mobility exercises

Denneroll exercises

LTX

Basic stretching exercises

Details:

7. Is there anyone who has been especially helpful?

8. What do you think about the health workshops?

9. Do you have any comments or questions about your care at this stage?

10. Is there anyone you would like a New Patient voucher for? This allows them a free consultation with the Chiropractor including a spine and posture examination

I am happy for my feedback and pictures to be used in office, on our social media and/or website:

Yes

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

YYYY

Start the process →

Progress REVIEW FORM 4

Your health awaits.