top of page

PROGRESS EXAM
QUESTIONNAIRE #1

Our goal is to offer the highest quality care possible. It is common to notice positive changes in your overall health and well-being as your nervous system function begins to improve. Please help us by responding to the following questions about your wellness care in our office. 

Please check those which pertain to your experience to date:

Pain
Spasms
Numbness/Tingling
Mobility
Sleeping
Digestion
Bowel Movements
Breathing
Thinking/Concentration
Irritability/Depression
Dizziness
Co-ordination
Immune System Function
Walking Ability
Sitting Ability
Driving Ability
Quality of Life
Please rate your overall progress on a scale of 1 (no improvement) to 10 (optimum)
Is your diet as healthy as it should be?
Would you like help with your diet/nutrition?
Are you exercising regularly?

Thanks for submitting! We have received it.

bottom of page