Return Confidential
Progress Assessment Form
FILL OUT THE FORM BELOW, AND THEN HIT THE 'PRINT' BUTTON AT THE BOTTOM.
BRING THE PRINTED FORM WITH YOU TO YOUR NEXT VISIT.
Name: Date
People usually notice very positive changes in their overall health and well-being as the function of their nervous system begins to improve. Please indicate if you have noticed changes in any of the following areas:
( = YES; = SIGNIFICANT IMPROVEMENT)
More Relaxed Improved Coordination FOR WOMEN:
More Rested Decreased Headaches More Regular Cycles
Stronger Improved Vision More Comfortable Cycles
More Alert Reduced Blood Pressure Improved Fertility
Better Memory Improved Bowel Function Improved Sexual Function
Thinking More Clearly Improved Digestion FOR CHILDREN:
Improved Moods Less Sinus Congestion Improved
Improved Sleep Breathing Improved Improved with Earaches
Improved Hearing Improved Immunity Improved Colic
Improved Balance Improved Allergies Less Bed Wetting
Increased Overall Comfort Fewer Colds/Flu Improved Behavior
Increased Back Comfort Walking is Easier Improved Sleep Patterns
Increased Neck Comfort Sitting is Easier FOR MEN:
Increased Flexibility Standing is Easier Less Prostate Irritation
Increased Joint Comfort Driving is Easier Better Sexual Function
Fewer Ear Problems Lifting is Easier Increased Fertility
COMFORT ZONE:
Please select where you think you are on the continuum:
DISEASE WELLNESS
  Multiple
Medications:
Poor Quality of Life;
Limited Function
& Potential.		   Poor
Health:
Symptoms;
Drug Therapy
& Surgery.		   Maintaining
Health:
No Symptoms;
Inconsistent
Nutrition.		   Good
Health:
Regular
Exercise;
Good
Nutrition.		 100%
Function:
Continuous
Development;
Wellness
Lifestyle.		  
1) Please indicate which direction you think you are heading towards:
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? (if yes, what changes have you made?):
Yes, please explain:
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) What aspects of our service are most appealing to you?
6) Have you recommended us to your family and/or friends?
Yes
No
7) What can we do to make your visits more enjoyable?
8) What have been your greatest accomplishments since your last progress visit?
9) What have been your greatest obstacles since your last progress visit?
Concerning the INITIAL reason you consulted our office, please let us know how you are doing:
IS YOUR INITIAL CONCERNS IMPROVING?  Yes   No
Please Explain:
Is there any specific feedback you’d like to give us about your progress so far?
Do you have any new health concerns that have arisen since your last assessment?  Yes   No
Please Explain:
Please Check All That Currently Apply
HEAD REGION: Hands Cold LOW BACK REGION cont:
Sinus (allergy) Loss of grip strength Slipped disc L1/L2/L3/L4/L5
Entire head pain Sore/swollen joint in fingers Low back feels out of place
Migraine headaches Arthritis in finters Stiffness with movement
Tension headaches MID BACK REGION Muscle spasms
Menstrual headaches Mid back pain Arthritis in low back region
Head feels heavy Pain between shoulder blades Better with ice
Loss of memory Sharp stabbing pain Better with heat
Fainting Dull achy pain HIP/LEG/FOOT REGION:
Light bothers eyes Muscle spasms Pain in buttocks (left/right)
Blurred or double vision Pain in kidney area Pain in hips (left/right)
Loss of balance CHEST REGION: Pain into legs (left/right)
Loss of taste Chest pain Pins/needles into legs (left/right)
Loss of hearing Shortness of breath KNEE REGION:
Dizziness Rib pain Knee pain (left/right)
Pain or ringing in ears Breast pain Outside knee pain (left/right)
NECK REGION: ABDOMEN REGION: Inside knee pain (left/right)
Pain in neck (left/right) Nervous stomach Leg cramps (left/right)
Neck pain with movement Nausea Foot cramps (left/right)
Pain on forward motion Gas pains Pins/needles in legs (left/right)
Pain on backward motion Constipation Numbness in legs (left/right)
Pain on turning head (left/right) Diarrhea Swelling in legs (left/right)
Pinched nerve feeling Hemorrhoids GENERAL:
Muscle spasms in neck LOW BACK REGION: Nervous or anxious
Grinding sounds in neck Lower back pain (left/right) Irritable
Neck Arthritis Pain when working Depressed
SHOULDER REGION: Pain when lifting Fatigue/run down feeling
Pain in arm (left/right) Pain when bending Loss of weight: lbs.
Pain in hands (left/right) Pain when standing Normal sleep: hrs
Pins/needles sensation (left/right) Pain when sitting Cigarettes: /day
Shoulder tension (left/right) Pain when coughing Coffee/tea: cups/day
Muscle spasms Pain when lying down Blood sugar problems
How would you rate your following lifestyle habits as they are currently, on a scale of 1 (poor) to 10 (great)?
Nutrition:    Exercise:    Mental Wellbeing:   
What are your goals in the above three areas for the next 3 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 Neck Support Pillow Meditation CD
Protein Supplement Back/Chair Support Books on Self Development
Multivitamin Specific Postural Exercises Workshops
Organic Produce Core Stability & Strength Journal recommendations
Calcium Supplement Exercise/ Stability Ball Psychotherapist referral
Prenatal Supplement Foam Roller Yoga studio referral
Probiotics Tubing Exercises  
Nutritional Info Session Exercise & Activity Workshop  
FFC employs the services of several other health professionals. Please let us know if you’d like to know more about and/or consult with:
Registered Massage Therapist:  Yes   No
Classical Homeopath:  Yes   No
Psychotherapist:  Yes   No
Holistic Nutritionist:  Yes   No
Are there any other types of health professionals (outside our clinic) that you would be interested in learning more about and/or being referred to?
Thank you so very much.
We sincerely appreciate having you participate in chiropractic care in our clinic.

Dr. Laura Foster & Dr. Danielle Warner