Progress Evaluation 3

3. How would you rate your improvement?
5. How would you rate the service in our office?
7. Why are you here?
MM slash DD slash YYYY
MM slash DD slash YYYY

1. Below you will find your initial pain rating on a scale of 0 to 10 with 10 being the worst pain and zero being no pain. In the current rating column please rate the pain that you are currently experiencing. Under frequency and improvements, please check all boxes that apply.

Does anything you do aggravate your condition(s):
Does anything relieve your discomfort?

At the time of your last progress evaluation, you indicated a limiting ability to perform the highlighted daily activities; please identify how your current condition is affecting your ability to carry out these activities.

MM slash DD slash YYYY
MM slash DD slash YYYY

Your central nervous system controls and coordinates everything. Please place a “C” next to the concerns or health challenges that you currently have. Place an “I” next to the concerns or health challenges that you have seen improve.

Bowel Problems
Menstrual Cycle
Thyroid Problems
Blood Pressure
Mid Back Pain
Neck Pain
Sinus Problem
Have you missed any appointments?
Have you been doing your at-home rehab as prescribed?
Which of the following programs are you doing to help improve the overall function of your body?
Are you signed up for the next Maximized Living MakeOver?
MM slash DD slash YYYY

Get Started on Your Wellness Transformation

Align your health naturally with one or a combination of these chiropractic essentials. We provide customized chiropractic services to help you find your unique path to transformation. Get started transforming your health today with Good Life Family.
Contact Details
Good Life Family Chiropractic
7011 Kentwell Lane #200
Lincoln, NE 68516
Tel: +1 402 413 8825
Email: frontdesk
Office Hours
Monday:8:00 am – 10:15 am
3:00 pm – 6:00 pm
Tuesday:3:00 pm- 5:10 pm
Wednesday:8:00 am – 10:15 am
3:00 pm – 6:00 pm
Thursday:3:00 pm – 6:00 pm
Friday:8:00 am – 10:15 am
Saturday:9:00 am – 10:15 am
© 2021 Danny Veiga, Good Life Family Chiropractic. 
                    All Rights Reserved.
linkedin facebook pinterest youtube rss twitter instagram facebook-blank rss-blank linkedin-blank pinterest youtube twitter instagram