Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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