trumotion.org - Progress Exam Questionnaire

Progress Exam Questionnaire

To help ensure that we are on track toward achieving your health goals, please tell us what type of changes you are experiencing as your body begins the natural healing process.
Patient Information

This information will be sent to your provider and will be kept as part of your patient records.
Name

First NameLast Name
Date

MonthDayYear
Date
Email address
example@example.com
Mobile phone number
Please enter a valid phone number.
Date of Birth

MonthDayYear
Date
Your Wellness Goal

Your initial health goals for care were:
First Goals:
How would you rate your progress toward the first goals so far?

1

2

3

4

5

1 is Worse, 5 is Improved
Second Goals:
How would you rate your progress toward the second goals so far?

1

2

3

4

5

1 is Worse, 5 is Improved
Third Goals:
How would you rate your progress toward the third goals so far?

1

2

3

4

5

1 is Worse, 5 is Improved
How are you doing?
Have you noticed any improvements in any of the following?

SleepingEmotional StressWalking & RunningChanging HabitsFlexibility & MobilityPain ManagementSittingFamily LifeEnergy LevelsWork Life
Tell us about any changes that you have noticed since beginning care
- Physical changes( ex: less pain, more mobility, feeling stronger, ect.)
- Health changes (ex: fewer illness, less severe symptoms, ect.)
- Emotional changes (ex: better mood regulation, less anxious, ect.)
- Energy & stress levels (ex: Sleeping better, more energy, happier, ect.)
Tell us about any new health challenges or stressors in your life
Your Health Progress
Your improvement so far is .....

Taking longer than expectedProgressing as expectedOccurring faster than expected
Rate the impact of these improvements on your health:

1

2

3

4

5

1 is No Impact, 5 is Great Impact
Rate the impact of these improvements on quality of life:

1

2

3

4

5

1 is No Impact, 5 is Great Impact
Office Evaluation: How are you doing?

We constantly strive to make our best even better for you and your family. Your feedback is important and appreciated! Thank you for helping us make a positive impact on our community!
How would you rate our doctor(s) on the following?
Care and Concern

1

2

3

4

5

1 is Poor, 5 is Excellent
Training & Competency

1

2

3

4

5

1 is Poor, 5 is Excellent
Comments about our doctor(s):
How would you rate our staff on the following?
Care and Concern

1

2

3

4

5

1 is Poor, 5 is Excellent
Training & Competency

1

2

3

4

5

1 is Poor, 5 is Excellent
Comments about our staff:
Practice Feedback
What do you like most about our office?
What would you like to change about our office, staff, or procedure to improve your experience?
How would you describe our educational efforts such as workshops, events, handouts, posters, ect.?

Exellent, I've learned a lot!Helpful & interestingCould be significantly improvedNot enough materials or eventsIneffective use of resourcesLeave some questions unanswered
Supports & Referrals

If you are experiencing positive results, please help spread the message! Thank you for helping us make a positive impact on our community!
Have you told your family & friends about chiropractic?

YesNo
What feedback and comments have you heard about others since beginning care?
Would you be willing to share how chiropractic has impacted your health?

Yes, I'll share my storyNot at this time
Our Practice grows through word of mouth and referrals. If you have loved ones experiencing health problems, please tell them about experience and/or list them below.
Name:
Relationship:
Phone Number:
Please enter a valid phone number.
May we contact them?

YesNo
Name:
Relationship:
Phone Number:
Please enter a valid phone number.
May we contact them?

YesNo
Name:
Relationship:
Phone Number:
Please enter a valid phone number.
May we contact them?

YesNo
Patient Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Progress Exam Questionnaire

Patient Information

Your Wellness Goal

How are you doing?

Your Health Progress

Office Evaluation: How are you doing?

Practice Feedback

Supports & Referrals