Intermediate Level Network Care Questionnaire

Intermediate Level Network Care Questionnaire

The following question will help you to explore in more detail than before what has changed and improved and what still needs to change.

What is it in your life and experience that you would like to transform next?

This is a very valuable time to reflect on your experience, make connections about your life, health and wellbeing that you haven’t made before and to prepare to make the most of your time with your chiropractor during the re-evaluation.

It’s also a time to raise your standards, set higher goals for your life.
Enjoy!
Your Name*

First NameLast Name
Intermediate Level Questionnaire
Please answer the following questions with regard to the time since beginning care in this office:
What was the primary reason you came for?
What improvements or changes have you seen in your symptoms and quality of life? (highlight any areas that have changed and add information below)
What is the next thing that you’d like to achieve? What’s your next goal?*
What two thought patterns (recurrent thoughts) would you like to experience LESS of?
Your care will continue to include physical and emotional improvements, even more so that we'll be able to include your thought habits as well.
What two thought patterns (recurrent thoughts) would you like to experience MORE of?
Why do you want to continue care?*
This questionnaire is the second of five, covering three levels of care.

This questionnaire belongs to Level 1 of Care, which helps your body to connect with tensions and release those in a way that perhaps your body hasn't been able to in years. It is also about safety, re-connection, ease, being embodied. This frees up the capacity to heal better again. Your body awareness will improve and you will much, allowing you to look after yourself better in future.

Level 2 of Care upgrades your body-mind. This is not just about release, but about transformation, even totally new strategies in your body and mind that didn't exist before. You are setting a new standard for how you'll feel, act and think.

Level 3 of Care leaves any opposition behind. No more tension, conflict, limitations. This is about living from the heart, not the head, purely about increased quality of life, gratitude, synchronicity, grace, awakening, intuition, community, sharing your gifts and about the legacy you leave for the world.

Each Level of Care has a physiological foundation. You will feel better and better, more and more expanded.

If you'd like to find out more about where you are at and how to experience more of the Levels of Care in an embodied way, please ask Dr Olaf.

The following questions refer to changes/events that may have happened to you since your last questionnaire was completed:
I have experienced the following marked mental, emotional,chemical and physical stresses during this period, in addition to those Ilisted in the last questionnaire I completed:
I have changes in the following areas of my life:
- Relationships - Home - Work - School -
Did you deal with these traumas or changes differently or inthe same way, as you would have before beginning care in this office?
I have changed my exercise…… meditation…… medication…… therapeutic……patterns. Please explain:
I have been in a car accident (R.T.A), workinjury, athletic injury. Please explain:
Is there anything else you would like to share or discuss with your chiropractor about your spinal progress or changes at this point of care?
I acknowledge that I am providing my details in accordance with the privacy policy of Naturally Empowered. To view the privacy policy click here.
I agree.
Should be Empty:

	far worse	worse	a little worse	same	a little better	better	much better
Strength
Comfort
Ease of Movement
Ease of recovery

	far worse	worse	a little worse	same	a little better	better	much better
Depth / Volume
Ease of breathing
Areas where I experienced breath
Ease of breath during exericse

	far worse	worse	a little worse	same	a little better	better	much better
Chest discomfort
Rapid heartbeat
Dizziness
Cold extremities

	far worse	worse	a little worse	same	a little better	better	much better
Appetite
Indigestion, heartburn
Wind
Ease in bowel movement
Ease in urination

	far worse	worse	a little worse	same	a little better	better	much better
Woman's cycle regularity
Woman's cycle comfort
Satisfaction with sexual function

	far worse	worse	a little worse	same	a little better	better	much better
Nervousness
Depression or lack of interest
Difficulty in falling asleep
Difficulty concentrating
Moodiness or temper
Fidgety or restless
Feelings of ease, peace
Over-react to life stresses (minor)
Over-react to life stresses (major)
Experience of release of spinal tension
Experience of body rhythms
Experience of gratitude