Quality of Life Survey

Patient Quality Of Life Survey
Date

MonthDayYear
Name
Please take several minutes to answer these questions so we can help you get better. (Please circle as many that apply)
a. medicationsb. Emergency Roomc. Routine Medicald. Exercisee. Nutrition/Dietf. Holistic Careg. Vitaminsh. ChiropracticOther
a. Bad Resultsb. Some Resultsc. great resultsd. Nothing Changede. Did not get worsef. Did not work very longg. Still tryingh. Confused
a. No one is affectedb. Haven't noticed any problemc. They tell me to do somethingd. People avoid me
a. Jobb. Kidsc. Future abilityd. Marriagee. Self-esteemf. Sleepg. Timeh. Financesi. Freedom
a. Family health problemsb. Heart diseasec. Cancerd. Diabetese.Arthritisf. Fibromyalgiag. Depressionh. Chronic Fatiguei. Need surgery
How has your health condition affected your job, relationships, finances, family, or other activities? Please give examples
What has that cost you? (time, money, happiness, freedom, sleep, promotion, etc.) Give 3 examples
What are you most concerned with regarding your problem?
Where do you picture yourself being in the next 1-3 years if this problem is not taken care of? Please be specific
What would be different/bette without this problem? Please be specific
What do you desire most to get from working with US?
What would that mean to you?
Should be Empty: