Please enable JavaScript in your browser to complete this form.Name: *FirstLastSelect a patient group:WomenMenChildrenGolden Athletes (60+ Years Old)While most chiropractic changes occur near the end of corrective care, we find that many patients can experience great changes sooner, as the nervous system begins to function optimally again. Please select any that you have already experienced:Improved digestionMore regular/comfortable cyclesImproved thyroid functionImproved sexual function/fertilityPositive mood changesLess stressImproved sleep/energyWhile most chiropractic changes occur near the end of corrective care, we find that many patients can experience great changes sooner, as the nervous system begins to function optimally again. Please select any that you have already experienced:Reduced prostate irritationImproved sexual function/fertilityReduced acid refluxImproved digestionImproved sleep/energyPositive mood changesLess stressWhile most chiropractic changes occur near the end of corrective care, we find that many patients can experience great changes sooner, as the nervous system begins to function optimally again. Please select any that you have already experienced:Improvement with colicImprovement with earachesImprovement with bed-wettingImproved behaviourBetter gradesAsthma/allergies relievedWhile most chiropractic changes occur near the end of corrective care, we find that many patients can experience great changes sooner, as the nervous system begins to function optimally again. Please select any that you have already experienced:Improved balanceImproved visionImproved coordinationImproved hearingImproved memoryWhat medications have you been able to reduce the dosage of or stop taking altogether since beginning chiropractic care? Please grade how well you have been doing witht the following: Keeping your chiropractic schedule: Selected Value: 0 Doing home exercises: Selected Value: 0 Doing your Denneroll (at home): Selected Value: 0 Implementing health strategies taught: Selected Value: 0 We are coming up on Phase II of your care - Chiropractic Wellness Care. On a scale of 1 to 10, how important is it for you to complete your care plan including Chiropractic Wellness Care and keep from losing your results so far? Selected Value: 0 What do you hope to get out of your wellness care? Retain current resultsGet even betterPrevent subluxationsPrevent degeneration/arthritisGet strongerMore energyBetter balanceFeel more relaxedBeing less nervous/anxiousSleep betterImproved digestionSignature: * Clear Signature Submit
