Home
About Us
Our Team
Facilities and Services
Fees
Success Stories
Workshops
NutriDyn Nutritional Support
Affiliates
Chiropractic
Chiropractic
New Patients
8 Weeks to Wellness
Massage
Fitness
8WW
Functional Fitness
Special Offers
Contact Us
Home
About Us
Our Team
Facilities and Services
Fees
Success Stories
Workshops
NutriDyn Nutritional Support
Affiliates
Chiropractic
Chiropractic
New Patients
8 Weeks to Wellness
Massage
Fitness
8WW
Functional Fitness
Special Offers
Contact Us
Progress check 3
Name
*
First Name
Last Name
1. What are your current health goals?
2. What changes have you noticed since beginning Chiropractic care?
3. On a scale of one to ten, rate the level of your overall improvement so far:
No Change
1
2
3
4
5
6
7
8
9
10
Major Change
4. Please tick if you are experiencing any of the following:
Increased energy
More balanced
Able to relax more
Feeling stronger
Feeling more alert
Better concentration
Please tick which of the following activities are easier:
Sleeping
Walking
Sitting
Bending/lifting
Driving
Standing
Working
Sports
5. How would you rate the efficiency and care of our staff?
Disorganised
1
2
3
4
5
6
7
8
9
10
Efficient and Caring
6. Is there anyone who has been especially helpful?
7. What do you like best about our centre?
8. Have you signed up to our weekly E-chats emails? Do you follow us on facebook and instagram? Do you need any help with signing up to any of these Would you consider writing us a review?
9. Would you like any additional information on our Massage, 8WW, Functional Fitness, Supplements or Health Workshops?
10. Is there anyone you would like a New Patient voucher for? This allows them a free consultation with the Chiropractor including a spine and posture examination
Consent
*
A Chiropractic adjustment is considered to be a safe and effective form of therapy for spinal conditions i.e. vertebral subluxation. A thorough examination, with or without x-rays has been performed to minimise any risk to you. If you have any questions about this, please ask your practitioner.
I have read the above statement and therefore consent to ongoing spinal adjustive Chiropractic treatment.
Date
*
MM
DD
YYYY
Thank you!
