Re-exam

Please kindly answer ALL questions as best as possible.

Name *

CPR-number *

Date *

Rate your level of improvement from start to now (1=no change, 10=big change) *

Have you recently had negative changes in your life that could affect your health? (new health challenges, stress at work, physical/mental trauma, new medication, family challenges, etc.)

Yes

What changes have you observed in your body / health since the beginning of your adjustment plan (even the smallest ones)?

What can you do now that you could not do before? (e.g. sports, daily tasks, eating specific foods, lifting children/grandchildren, etc.)

Have you noticed if any of the SYSTEMS in the body work better since the misalignments have been reduced (Ex. Breathing, Digestion, Circulation, Immune System, Reproduction, Musculature, etc.?)

What medications have you been able to REDUCE, or STOP completely, since starting your chiropractic adjustments?

Have you made any changes in your daily habits to minimize misalignments / improve your health? (e.g. started exercising, changed eating habits, got tools to deal with stress, improved relationship, better job, etc.

HOW MUCH does this discomfort affect your life in regards to your job/daily activities now? (1= very little, 10= a lot) *

HOW MUCH does this discomfort affect your life in regards to past time/home activities now? (1= very little, 10= a lot) *

HOW MUCH does this discomfort affect your life in regards to sleep now? (1= very little, 10= a lot) *

HOW MUCH does this discomfort affect your life in regards to your energy level now? (1= very little, 10= a lot) *

HOW MUCH does this discomfort affect your life in regards to your mood now? (1= very little, 10= a lot) *

HOW stressed is your body now? (1= very little, 10= a lot) *

HOW stressed are you mentally now? (1= very little, 10= a lot) *

Have you experienced any chiropractic miracles?

Improved digestion

Less stress in the body

Improved sexuality / fertility

Positive mood changes