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To help ensure that we are on track toward achieving your health goals, please tell us what types of changes you are experiencing as your body begins the natural healing process.

Name

First NameLast Name

Date

What were your initial goals for Chiropractic care?

Goal #1

2

Worse

3

Worse

Have you noticed any improvements in the following?

Would you say your improvement is

Progressing at the speed you expected

Would you say your improvement is

Taking longer than expected

On a scale of zero to ten, rate the impact of this improvement on your QUALITY OF LIFE

We constantly strive to make our best even better for you and your family. Your feedback is important and appreciated.

Please mention any general comments about the office

Is there anything our staff can do to further improve the quality of your care?

Y

Would you be willing to share how chiropractic care has improved your life?N

Thank you for helping us make a positive impact on the community.

Progress Exam Questionnaire