Wellness progress report form

Name

First Name

Last Name

1. What are your current health goals?

2. How do you find your regular adjustments help you?

3. On a scale of 1-being poor, to 10-being brilliant, please rate yourself on the following:

Energy

Sleep

Nutrition

Exercise

4. How many times a week do you perform your Dennerol, HTU, LTX or basic stretches?

5. How much water do you drink per day?

6. Do you have any questions or concerns you wish us to address?

7. Do you take any supplements or have any questions about this?

8. 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

YYYY

Start the process →

Wellness progress report form

Your health awaits.