Wellness Check-In Form

We are here to help you achieve your health goals. Please answer the following questions thoughtfully so your doctor can provide you with the best care possible.

Six Month Health Review

Have you had any new or significant changes in your health in the past six months?

Please explain any changes in your health.

Have you had any changes in occupation or occupational activity in the past six months? (ie, Sitting more, standing more, lifting, bending, etc.)

Please explain any changes here.

Have you started any new fitness, athletic, or recreational activities in the past six months?

Please explain new activities here.

Do you have any new health concerns that you would like to discuss with your doctor?

Please explain any new health concerns.

Have you started, or stopped, any medication in the past six months?

Please list medications here.

General Health Goals

What are your top 1-2 health goals for the next six months? (ie, better sleep, less pain, improved mobility, more energy, weight management, better nutrition, etc...)

Is there anything you are struggling with that you would like support on? (This could include stress, digestion, energy, posture, sleep, etc...)

Foundation & Posture Review

Your posture affects how you move, sleep, and feel. Poor alignment can lead to pain, fatigue, and long-term stress on your spine and joints. This includes how you sit at work, how you sleep, and how your feet support your body. Answer the following to give your doctor a snapshot of your current posture habits.

Do you ever experience foot, ankle, knee, hip, or lower back discomfort during your daily activities or workouts?

Have you had your arches or foot alignment professionally evaluated?

Do you currently use arch support in your shoes?

If you answered "yes" to the previous question, how old are your current orthotics/inserts?

Do you wake up with stiffness, pain, or discomfort?

Are you a side, back, or stomach sleeper?

How old is your mattress?

How old is your pillow?

Would you like help with your sleep posture to get a better night's rest?

How are your ergonomics at work/school/home?

Motion Is Lotion

Regular movement keeps your spine healthy, boosts circulation, supports mood, and helps your nervous system respond better to chiropractic care. It doesn’t have to be intense — even small, consistent activity makes a big difference!

Let’s get a snapshot of your current habits…

How would you describe your current fitness or movement routine?

If you do not currently exercise regularly, but would like to, what is the biggest obstacle that stands in your way?

If you are looking for help with an exercise routine, what area(s) of your body would you like to work on? (Check all that apply.)

If you could get help with your fitness routine, what would you like to work on? (Check all that apply.)

Fueling Your Health

What you eat directly impacts your energy, immune function, inflammation levels, and how well your body responds to chiropractic care. Just like you wouldn’t fuel a high-performance car with low-grade gas, your body needs the right nutrients to function at its best.

With that in mind…

How would you rate your current eating habits?

Do you crave sugar, caffeine, or carbs during the day?

Do you ever experience dips in energy, mood, or focus between meals?

Are you currently taking any of the following? (check all that apply)

Where do you purchase your vitamins/supplements?

Would you like to learn about natural solutions for any of the following health concerns: (Check all that apply.)

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.

What health condition/concern do you feel we can help your family member/friend with?

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