New Patient Health Goals Survey

Please help us better serve you by answering the following questions before the doctor reviews your case history. Thank you!

1. My view of health is:

a) Having no pain.

b) Having no pain and my body functions working as they were meant to be.

c) Other______________________________________________________.

d) Not sure.

2. My goal or reason I am consulting with the doctor is as follows:

a) I want to be rid of my pain as soon as is possible.

b) I not only want to be rid of my pain, but I want the cause of my condition stabilized so that I can be free to return to my normal lifestyle without my condition worsening.

c) I want all of the above plus I want the doctor to make whatever other recommendations that might be necessary to prevent similar problems in the future and to maintain my health.

d) I want the doctor to make whatever recommendations are best for me.

e) Other _______________________________________________________.

f) I am not sure right now.

3. My current understanding of Chiropractic is:

a) I had no understanding about what Chiropractic was before I arrived here today.

b) I have limited understanding of Chiropractic through friends or family members.

c) I feel I have a very good understanding of Chiropractic.

d) I feel Chiropractic is_____________________________________________.

4. What are your expectations about Chiropractic and your visit with our office?

______________________________________________________________________________

______________________________________________________________________________

Patient Name: ____________________________ Date: __________________

Thank you for your assistance. We look forward to helping you with your health needs. Please be assured that we are a “Patient” based practice; your health needs always come first.