Patient Progress Evaluation
About 5 minutes. Your answers help us care for you.
Patient Information
Name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Today's date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How likely are you to recommend Absolute Chiropractic to a friend or family member?
*
Not at all likely
0
1
2
3
4
5
6
7
8
9
Extremely likely
10
0 is Not at all likely, 10 is Extremely likely
What is the main reason for your score?
Care Changes and Health Progress
Are there any changes you and/or your child have noticed since the start of your care (even if minor)?
Positive
Negative
What's one sign you've noticed that your nervous system is healing or adapting better?
Have you and/or your child noticed any SYSTEMS of the body functioning better since your subluxations have been reduced (e.g. Respiratory, Digestive, Circulation, Immune, Muscular, Reproductive, etc.)?
What medications have you and/or your child been able to REDUCE the dosage of or STOP taking altogether since beginning Chiropractic Care?
Chiropractic Miracles Checklist
While most of our Chiropractic Miracles occur near the end of Corrective Care, we find that many patients can experience these miracles sooner, as the nervous system begins to function optimally again. Please check or write in any MIRACLES listed below that you have already experienced.
Women
Improved digestion
More regular/comfortable cycles
Improved thyroid function
Improved sexual function/fertility
Positive mood changes
Improved sleep/energy
Other
Men
Reduced prostate irritation
Improved sexual function/fertility
Reduced acid reflux
Improved digestion
Improved sleep/energy
Less stress
Other
Children
Improvement with colic
Improvement with earaches
Improvement with bed-wetting
Improved behavior
Better grades
Asthma/Allergies relieved
Other
Golden Athletes (60+ Years Old)
Improved balance
Improved coordination
Improved memory
Improved vision
Improved hearing
Other
Questions, Social Follow-up, and Reviews
Do you have any questions for the Doctor regarding your health?
What do you like most about our office?
Have you liked our Absolute Chiropractic page on Instagram?
Yes
No
Thank you! See what's new
Follow us on Instagram
Would you like an easy guide on how to leave us a Google review?
Yes
No
Leave us a Google review
Referral Entries
Please list names of people you feel would benefit from a consultation and EVALUATION. Please check YES if you would like us to call these referrals on your behalf for their initial evaluation.
Referral 1 Name
Referral 1 Cell #
Please enter a valid phone number.
Format: (000) 000-0000.
Referral 1 Call on my behalf?
Yes
No
Referral 2 Name
Referral 2 Cell #
Please enter a valid phone number.
Format: (000) 000-0000.
Referral 2 Call on my behalf?
Yes
No
Free Seminar Organization Details
Are you a member of a group or organization that would like the Doctor to present a FREE seminar on: Stress, Nutrition/Weight Loss, Healthy Living to 100, Sleep, Women's Health, OR a health topic of your choice?
Group/Organization Name
Contact Person
First Name
Last Name
City
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Topic
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Doctor
Attempt 1 date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Attempt 1 outcome
Please Select
reached
booked
left message
no answer
duplicate
in person
Attempt 2 date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Attempt 2 outcome
Please Select
reached
booked
left message
no answer
duplicate
in person
Red flag
Yes
What they said
Ladder rung
Please Select
none
1 Fan
2 Champion
3 Advocate
4 Ambassador
Submit
Should be Empty: