drvalchiropractic.com - Current Patient Re-Exam Form

Re-examination / Assessment of Improvement
Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
People usually notice very positive changes in their overall health and well-being as the function of the nervous system begins to improve. Please indicate if you have noticed changes in any of the following areas.

Areas of Improvement

WOMEN

CHILDREN

Rows	Yes	Significant Improvement
Improvement with colic
Improvement with earaches
Improvement with bed-wetting
Improved behavior

MEN

Rows	Yes	Significant Improvement
Reduced prostate irritation
Improved sexual function
Improved fertility

Please select your level of progress to date:

1

2

3

4

5

6

7

8

9

10

1 is No change, 10 is Resolved
Are there areas of your care where you would like additional information?
Would it help you to refer someone if you had a gift certificate to give to them?
Name
Relationship to patient
Health Problem
Address

Street Address

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Postal / Zip Code
Are you a member of a group or organization that would like the Doctor to present a FREE seminar on: Healthy Living to 100, Performance Nutrition, Headaches, Stress Less, Women’s Health, Spinal Hygiene?
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Contact Person
City
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

Re-examination / Assessment of Improvement