Quality of Life Survey

Full Name

Please answer these questions so we can help you get better.

(Please check ALL that apply)

How have you taken care of your health in the past?

Medications

Emergency Room

Routine Medical

Exercise

Nutrition/Diet

Holistic Care

Vitamins

Chiropractic

Other

How did the previous method(s) work out for you?

Bad Results

Some Results

Great Results

Nothing Changed

Did Not Get Worse

Did Not Work Very Long

Still Trying

Confused

How have others been affected by your health condition?

No One Is Affected

Haven’t Noticed Any Problem

They Tell Me To Do Something

People Avoid Me

What are you afraid this might be (or beginning) to affect (or will affect)?

Job

Kids

Future Ability

Marriage

Self-Esteem

Sleep

Time

Finances

Freedom

Are there health conditions you are afraid this might turn into?

Family Health Problems

Heart Disease

Cancer

Diabetes

Arthritis

Fibromyalgia

Depression

Chronic Fatigue

Need Surgery

How has your health condition affected your job, relationships, finances, family, or other activities? Please give examples:

What has that cost you? (time, money, happiness, freedom, sleep, promotion, etc.). Give 3 examples:

1
2
3

What are you most concerned with regarding your problem?

Where do you picture yourself being in the next 1-3 years if this problem is not taken care of? Please be specific.

What would be different/better without this problem? Please be specific.

What do you desire most to get from working with us?

What would that mean to you?