PATIENT PROGRESS EXAM REPORT

We pride ourselves on excellent service of Chiropractic Care here at Destination Chiropractic.

Please rate our Service and Competency:

Please rate our Service & Competency

ON A SCALE OF 1 TO 10, PLEASE CHECK OFF TO RATE YOUR LEVEL OF IMPROVEMENT SO FAR:

Please rate your level of improvement so far

Are there any changes you have noticed since the start of your care (even if minor)?

We correct subluxations in this office - How would you define SUBLUXATION in your own words?

Have you noticed any SYSTEMS of the body functioning better since your subluxations have been reduced (e.g. Respiratory, Digestive, Circulation, Immune, Muscular, Reproductive, etc.)?

What medications have you been able to REDUCE the dosage of or STOP taking altogether since beginning Chiropractic Care?

While most of our Chiropractic Miracles occur near the end of Corrective Care, we find that many patients can experience these miracles sooner, as the nervous system begins to function optimally again. Please select any MIRACLES listed below that you have already experienced.

WOMEN

Others not listed (women):

CHILDREN

Others not listed (children):

MEN

Others not listed (men):

GOLDEN ATHLETES (60+ in age)

Others not listed (golden athletes):

Do you have any questions for our Doctors regarding your health?

What do you like most about our office?

Have you shared one of our posts on Facebook yet?

Would you like a guide on how to leave us a Google review?

As with all private professionals, our practice is built upon referrals. Please list the name of someone you feel would benefit from a DISCOUNTED new patient appointment.

Contact them?

Yes

Are you a member of a group or organization that would like the Doctor to present a FREE lunch and learn on: How to Stay Healthy in the Workplace?

Group or organization name:

Contact Person's Email Address

Contact Person's Phone Number