PI Re-evaluation
About 5 minutes. Your answers help us care for you.
Patient Information
Full 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 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?
We correct subluxations in this office. How would you define SUBLUXATION in your own words?
Have you 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 been able to REDUCE the dosage of or STOP taking altogether since beginning Chiropractic Care?
Have you been to our BETTER FASTER WORKSHOP? (We find that patients who attend heal faster and save money after this class, as we teach you how NOT to see a Doctor)
YES
NO
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
Have you provided us with a Google Review yet?
Yes
No
Leave us a Google review
Referral Entries
As with all private professionals, our practice is built upon referrals. 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
Referral 3 Name
Referral 3 Cell #
Please enter a valid phone number.
Format: (000) 000-0000.
Referral 3 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
Quadruple Visual Analogue Scale
Main complaint
1 - What is your pain RIGHT NOW?
No pain
0
1
2
3
4
5
6
7
8
9
Worst possible pain
10
0 is No pain, 10 is Worst possible pain
2 - What is your TYPICAL or AVERAGE pain?
No pain
0
1
2
3
4
5
6
7
8
9
Worst possible pain
10
0 is No pain, 10 is Worst possible pain
3 - What is your pain level AT ITS BEST (how close to "0" does your pain get at its best)?
No pain
0
1
2
3
4
5
6
7
8
9
Worst possible pain
10
0 is No pain, 10 is Worst possible pain
4 - What is your pain level AT ITS WORST (how close to "10" does your pain get at its worst)?
No pain
0
1
2
3
4
5
6
7
8
9
Worst possible pain
10
0 is No pain, 10 is Worst possible pain
Other comments:
Neck Disability Index
This questionnaire is designed to help us better understand how your neck pain affects your ability to manage everyday life activities. Please mark in each section the ONE box that applies to you. Although you may consider that two of the statements in any one section relate to you, please mark the box that most closely describes your present-day situation.
Section 1 - Pain Intensity
*
I have no neck pain at the moment.
The pain is very mild at the moment.
The pain is moderate at the moment.
The pain is fairly severe at the moment.
The pain is very severe at the moment.
The pain is the worst imaginable at the moment.
Section 2 - Personal Care
*
I can look after myself normally without causing extra neck pain.
I can look after myself normally, but it causes extra neck pain.
It is painful to look after myself, and I am slow and careful.
I need some help but manage most of my personal care.
I need help every day in most aspects of self-care.
I do not get dressed. I wash with difficulty and stay in bed.
Section 3 - Lifting
*
I can lift heavy weights without causing extra neck pain.
I can lift heavy weights, but it gives me extra neck pain.
Neck pain prevents me from lifting heavy weights off the floor but I can manage if items are conveniently positioned, ie. on a table.
Neck pain prevents me from lifting heavy weights, but I can manage light weights if they are conveniently positioned.
I can lift only very light weights.
I cannot lift or carry anything at all.
Section 4 - Reading
*
I can read as much as I want with no neck pain.
I can read as much as I want with slight neck pain.
I can read as much as I want with moderate neck pain.
I can't read as much as I want because of moderate neck pain.
I can't read as much as I want because of severe neck pain.
I can't read at all.
Section 5 - Headaches
*
I have no headaches at all.
I have slight headaches that come infrequently.
I have moderate headaches that come infrequently.
I have moderate headaches that come frequently.
I have severe headaches that come frequently.
I have headaches almost all the time.
Section 6 - Concentration
*
I can concentrate fully without difficulty.
I can concentrate fully with slight difficulty.
I have a fair degree of difficulty concentrating.
I have a lot of difficulty concentrating.
I have a great deal of difficulty concentrating.
I can't concentrate at all.
Section 7 - Work
*
I can do as much work as I want.
I can only do my usual work, but no more.
I can do most of my usual work, but no more.
I can't do my usual work.
I can hardly do any work at all.
I can't do any work at all.
Section 8 - Driving
*
I can drive my car without neck pain.
I can drive my car with only slight neck pain.
I can drive as long as I want with moderate neck pain.
I can't drive as long as I want because of moderate neck pain.
I can hardly drive at all because of severe neck pain.
I can't drive my car at all because of neck pain.
Section 9 - Sleeping
*
I have no trouble sleeping.
My sleep is slightly disturbed for less than 1 hour.
My sleep is mildly disturbed for up to 1-2 hours.
My sleep is moderately disturbed for up to 2-3 hours.
My sleep is greatly disturbed for up to 3-5 hours.
My sleep is completely disturbed for up to 5-7 hours.
Section 10 - Recreation
*
I am able to engage in all my recreational activities with no neck pain at all.
I am able to engage in all my recreational activities with some neck pain.
I am able to engage in most, but not all of my recreational activities because of pain in my neck.
I am able to engage in a few of my recreational activities because of neck pain.
I can hardly do recreational activities due to neck pain.
I can't do any recreational activities due to neck pain.
NDI Score (out of 50)
The Revised Oswestry Disability Index (for low back pain/dysfunction)
This questionnaire has been designed to give the doctor information as to how your back pain has affected your ability to manage everyday life. Please answer every section and mark in each section only the ONE box that applies to you. We realize that you may consider that two of the statements in any one section relate to you, but please just mark the box that most closely describes your problem.
Section 1 - Pain Intensity
*
The pain comes and goes and is very mild.
The pain is mild and does not vary much.
The pain comes and goes and is moderate.
The pain is moderate and does not vary much.
The pain comes and goes and is very severe.
The pain is severe and does not vary much.
Section 2 - Personal Care
*
I would not have to change my way of washing or dressing in order to avoid pain.
I do not normally change my way of washing or dressing even though it causes some pain.
Washing and dressing increases the pain, but I manage not to change my way of doing it.
Washing and dressing increases the pain and I find it necessary to change my way of doing it.
Because of the pain, I am unable to do some washing and dressing without help.
Because of the pain, I am unable to do any washing and dressing without help.
Section 3 - Lifting
*
I can lift heavy weights without extra pain.
I can lift heavy weights, but it causes extra pain.
Pain prevents me from lifting heavy weights off the floor, but I manage if they are conveniently positioned (e.g., on a table).
Pain prevents me from lifting heavy weights off the floor.
Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned.
I can only lift very light weights at the most.
Section 4 - Walking
*
I have no pain on walking.
I have some pain on walking, but it does not increase with distance.
I cannot walk more than one mile without increasing pain.
I cannot walk more than 1/2 mile without increasing pain.
I cannot walk more than 1/4 mile without increasing pain.
I cannot walk at all without increasing pain.
Section 5 - Sitting
*
I can sit in any chair as long as I like.
I can only sit in my favorite chair as long as I like.
Pain prevents me from sitting more than one hour.
Pain prevents me from sitting more than 1/2 hour.
Pain prevents me from sitting more than 10 minutes.
I avoid sitting because it increases pain right away.
Section 6 - Standing
*
I can stand as long as I want without pain.
I have some pain on standing, but it does not increase with time.
I cannot stand for longer than one hour without increasing pain.
I cannot stand for longer than 1/2 hour without increasing pain.
I cannot stand for longer than 10 minutes without increasing pain.
I avoid standing because it increases the pain right away.
Section 7 - Sleeping
*
I get no pain in bed.
I get pain in bed, but it does not prevent me from sleeping well.
Because of pain, my normal night's sleep is reduced by less than 1/4.
Because of pain, my normal night's sleep is reduced by less than 1/2.
Because of pain, my normal night's sleep is reduced by less than 3/4.
Pain prevents me from sleeping at all.
Section 8 - Social Life
*
My social life is normal and gives me no pain.
My social life is normal, but increases the degree of pain.
Pain has no significant effect on my social life apart from limiting my more energetic interests, e.g., dancing, etc.
Pain has restricted my social life and I do not go out very often.
Pain has restricted my social life to my home.
I have hardly any social life because of the pain.
Section 9 - Travelling
*
I get no pain while travelling.
I get some pain while travelling, but none of my usual forms of travel makes it any worse.
I get extra pain while travelling, but it does not compel me to seek alternative forms of travel.
I get extra pain while travelling, which compels me to seek alternative forms of travel.
Pain restricts all forms of travel.
Pain prevents all forms of travel except that done lying down.
Section 10 - Changing Degree of Pain
*
My pain is rapidly getting better.
My pain fluctuates, but is definitively getting better.
My pain seems to be getting better, but improvement is slow at present.
My pain is neither getting better nor worse.
My pain is gradually worsening.
My pain is rapidly worsening.
Oswestry Score (out of 50)
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Doctor
Attempt 1 date
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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: