Download Re-examination/Assessment of Improvement

Re-examination/Assessment of Improvement
Name:
Date:
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 (X = yes, XX = significant
improvement).
More relaxed
More rested
Stronger
More alert
More energy
Better memory
Thinking more clearly
Improved moods
Improved sleep
Improved hearing
Improved balance
Improved coordination
Decreased headaches
Improved vision
Reduced blood pressure
Improved bowel movements
Improved digestion
Decreased sinus congestion
Breathing has improved
Improved immunity
Improved allergies
Fewer colds/flu
Women:
Children:
More regular cycles
More comfortable cycles
Improved fertility
Improved sexual function
Increased overall comfort
Increased back comfort
Increased neck comfort
Increased flexibility
Increased joint comfort
Walking is easier
Sitting is easier
Standing is easier
Lifting is easier
Bending is easier
Driving is easier
Men:
Improvement with colic
Improvement with earaches
Improvement with bed-wetting
Improved behavior
Reduced prostate irritation
Improved sexual function
Increased fertility
Please mark with an X in one box on the continuum where you think you are.
Comfort Zone
DISEASE
MULTIPLE MEDICATIONS
Poor Quality of Life
Limited Function & Potential
WELLNESS
POOR HEALTH
Symptoms
Drug Therapy & Surgery
Losing Normal Function
MAINTAINING HEALTH
No Symptoms
Inconsistent Nutrition & Exercise
1)Please indicate which direction you think you are heading:
GOOD HEALTH
Regular Exercise
Good Nutrition
Minimal Nerve Interference
100% FUNCTION
Continuous Development
Wellness Lifestyle
Towards Disease
Towards Wellness
2) On a scale of 1 to 10, how satisfied are you with the quality of life improvements that you
have made while under care in our office thus far?
Not at all 0
5
10 Completely!
3) Have you made any changes in your lifestyle (drinking more water, exercising more, etc.)
since you began care in our office? Yes or No and if yes, what changes have you made?
Yes
:
No
4) On a scale of 1 to 10, how happy are you with your decision to improve your health and
well-being at our office?
Not at all 0
5
10 Completely!
5) Which aspects of our service are most appealing to you?
6) How has your family benefited from your care in our office? Please describe:
CHASE Clinic — Reaching out to our community with helping hands
3527 – 18 St SW Calgary, AB
www.welladjusted.ca
Ph: 403.246.0334
7) Have you recommended us to your friends and/or family?
Yes
No
8) What can we do to make your visits more enjoyable?
9) What have been your greatest accomplishments since your last re-examination?
10) What have been your greatest obstacles since your last re-examination?
How would you rate your following lifestyle habits as they are currently on a scale from 1 Poor to 10
Great?
Nutrition
Exercise
Mental Wellbeing
What are your goals in the above three areas for the next three months?
Our goal is to help you improve your spinal health and the overall function of your nervous system.
Please check off items or activities you would like to discuss adding to your health program.
EATING WELL
MOVING WELL
THINK WELL
Omega 3 fatty acids
Cervical support pillow
Meditation CD
Protein supplement
Specific postural exercises
Books on self development
Multivitamin
Core stability & strength
Affirmation CD & books for kids
Organic produce
Exercise/stability ball
Sunrise alarm
Calcium supplement
Foam roller
Quit smoking CD
Prenatal supplement
Orthotics
Weight loss CD
Nutrition info session
Lumbar chair support
Exercise & activity workshop
Implementing change workshop
How can we help you achieve these goals? (If we are unable to provide direct assistance we will strive to
guide you in the most appropriate direction.)
CHASE Clinic — Reaching out to our community with helping hands
3527 – 18 St SW Calgary, AB
www.welladjusted.ca
Ph: 403.246.0334
Please Check All That Apply
HEAD:
Headache
Sinus (allergy)
Entire head
Back of head
Forehead
Temples
Migraine
Head feels heavy
Loss of memory
Fainting
Light bothers eyes
Blurred vision
Double vision
Loss of vision
Loss of balance
Loss of taste
Loss of hearing
Dizziness
Pain in ears
Ringing or noises in ears
Hands cold
Loss of grip strength
Sore/Swollen joints in fingers
Arthritis in fingers
MIDBACK:
Mid-back pain
Pain between shoulder blades
Sharp stabbing
Dull ache
Muscle spasms
Pain in kidney area
NECK:
Pain in neck
Neck pain with movement
Forward
Backward
Turning (L or R)
Bending (L or R)
Pinched nerve in neck
Neck feels out of place
Muscle spasms in neck
Grinding sounds in neck
Popping sounds in neck
Arthritis in neck
SHOULDERS:
Pain in joint (L or R)
Pain across shoulders
Bursitis (L or R)
Arthritis
Can’t raise arm
Above shoulder level
Overhead
Tension in shoulders
Pinched nerve in shoulder(L or R)
Muscle spasms in shoulder
ARMS AND HANDS:
Pain in arm
Tennis elbow
Pain in hands/fingers (L or R)
Pins and needles sensation (L or R)
Numbness (L or R)
CHEST:
Chest pain
Shortness of breath
Rib pain
Breast pain
Irregular heartbeat
ABDOMEN:
Nervous stomach
Food I can’t eat
Nausea
Gas
Constipation
Diarrhea
Hemorrhoids
Knee pain (L or R)
Outside
Inside
Leg cramps
Feet cramps
Pins and needles in legs
Numbness in legs/feet
Swelling in legs/feet
GENERAL:
Nervousness
Irritable
Depressed
Fatigue
Run-down feeling
Normal sleep
Hrs
Loss of sleep
Loss of weight
lbs
Weight gain
lbs
Coffee
cups/day
Tea
cups/day
Cigarettes
packs/day
Diabetes
Hypoglycemia
Numbness
Tingling
Other
LOW BACK:
Lower back pain (L or R)
Upper lumbar
Lower Lumbar
Low back pain is worse when
Working
Lifting
Stooping
Standing
Sitting
Bending
Coughing
Lying down
Walking
Pain is relieved when
Slipped disc
Low back feels out of place
Muscle spasm
Arthritis
How you feel is a poor
judge of your health. Most
people are suffering from ill
health even before a
symptom appears. Vertebral
Subluxations (spinal nerve
interference) can occur in
your spine for decades even
before symptoms occur,
interfering with the proper
functioning of the body’s
most vital organs causing
your body to eventually
dysfunction and breakdown.
HIPS, LEGS, & FEET
Pain in buttocks(L or R)
Pain in hip joint(L or R)
Pain down leg (L or R)
CHASE Clinic — Reaching out to our community with helping hands
3527 – 18 St SW Calgary, AB
www.welladjusted.ca
Ph: 403.246.0334