Progress Form

Please complete the following information to help your doctor track your health progress.

First Name *

Last Name *

What health concern, or health goal, initially brought you into the office? *

How much has your health concern improved to date? *

Which symptoms have improved? *

What symptoms, if any, do you still have? *

Overall Frequency of Complaint (choose one) *

Constant - 100% of the time

Frequent - 75%

Intermittent - 50%

Occasional - 25%

What improvements have you noticed since beginning your care with us?

(Please check all that apply.)

Physical Changes

Less Pain

More Mobility

Feeling Stronger

Health Changes

Fewer Illnesses

Less Severe Symptoms

Improved Appetite

Emotional Changes

Better Mood Regulation

Less Anxious

Less Nervous

Happier

Energy & Stress Level

Sleeping Better

More Relaxed

More Energy

More Alert

Are there any NEW health changes, conditions, or stressors in your life?

No

Yes (Please Explain Below)

If yes, please explain:

My health and quality of life improvement so far is:

Progressing as Expected

Progressing Faster Than Expected

Progressing Slower Thank Exprected

Are there any questions or concerns regarding your progress so far?*

No

Yes (Please Explain Below)

Please Explain:

Do you intend to continue your care to help further improve your health? *

Yes

No

Will follow my chiropractor's recommendations

Please let us know what you enjoy most about our office: *

Please let us know if there is anything we can do to improve your experience with us. *

Help Us Help Others!

Now that you are experiencing the benefits of chiropractic care, do you have a friend or family member that would benefit from a check-up?

Yes! Please give me a Referral Gift Packet for my friend/family member.

Signature *

Clear

Date Signed: *

Printed Name:

Email *

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.