Patient Quality of Life Survey

Patient Quality of Life Survey

Please take several minutes to answer these questions so we can help you better. It will be worth your time!
Which Office Do You Prefer?*
First Name*
Last Name*
Email*
example@example.com
Phone*
How have you taken care of your health in the past?*

MedicationsNutrition/DietEmergency RoomHolistic CareRoutine MedicalVitaminsExerciseChiropracticN/AOther
How did the previous method(s) work out for you?*

Poor ResultsDid Not Get WorseSome ResultsDid Not Work Very LongGreat ResultsStill TryingNothing ChangedConfusedN/AOther
How have others been affected by your health condition?*

No One Is AffectedThey Tell Me to Do SomethingHaven't Noticed Any IssuesPeople Avoid MeI'm Afraid I'm Starting to Change as a Person
What are you afraid this might be (or beginning) to affect (or will affect)?*

JobSleepKidsTimeFuture AbilitiesFinancesMarriageFreedomSelf-EsteemOther
Are there any health conditions you are afraid this might turn into?*

Family Health ProblemsFibromyalgiaHeart DiseaseDepressionCancerChronic FatigueDiabetesNeeding SurgeryArthritisOther
How has your health condition affected your job, relationships, finances, family, or other activities? Please give examples.*
What has this cost you? (time, money, happiness, freedom, sleep, promotions, etc.) Give three examples in order of most troublesome. *
1. 
2. 
3.
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 improve if you didn't have this problem? Please be specific.*
What do you desire most to get from working with us?*
If we could help you with your concerns, what would it mean to you?*
Imagine everything you have shared with us. Now imagine these issues being completely reversed or greatly improved. What would it mean to you? Your health, relationships, work, quality of life, etc.
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