Progress Questionnaire

Name

Date

Our goal at Westwood Family Chiropractic is to offer the highest quality chiropractic care to you. your family and the community Would you help us by responding to these questions about your progress?

Changes often happen quickly during your care as your body begins the natural healing process. It's been 3 months since you began care. Please let us know the progress and changes you are experiencing.

1. How do your adjustments feel?

2.What changes have you noticed since beginning care?

Physical changes

Health changes

Emotional changes

On a scale of zero to five. rate the level of improvement on a physical level. No change

On a scale of zero to five, rate the impact of this improvement on a mental or emotional level

Would you say the changes you are experiencing are

Greater than expectedLess than expected

Please explain

Have the doctors sufficiently explained the benefits of long term chiropractic care relative to your exam findings?

YN

Do you understand why children would benefit from chiropractic care?

YN

If you have children. do you have any hesitation to have their spines evaluated?

YN

How would you rate the commitment. training, qualifications and competency of our staff?

Is there a member of our team (doctor or staff) who has been especially helpful?

What would you change about our staff. office, or procedures to improve the quality of care?

What do you like most about our office?

We strive to fully inform our patients about their care and explain how chiropractic relates to their health. How would you describe our educational efforts?

Excellent, I've learned a lotHelpful and interestingStill leaves some questions unanswered

Do your friends or family offer you positive support when you tell them about your chiropractic program of care?

YesNoN/A

What kind of comments (if any) have you heard from people when you've told them about chiropractic?

Our practice has grown through referrals. We are honored to care for friends and family referred to us by our existing patients. Some people come for an answer to their spine or health problems and others come to prevent, improve or optimize their health. Please allow us to help the people you care about by listing their names below. A $75 gift certificate will be printed for them to be used toward a chiropractic examination

Name

Relationship

Name

Relationship

Name

Relationship

Please mention any other general comments about our office

Signature

Clear