Retest Questionaire
BODY SCAN RETEST PROGRESS QUESTIONNAIRE
Name Date
- How do you classify your improvement so far since beginning your care?
Excellent Good Fair Poor - On a scale of 1 to 10, with 10 being the best, how would you rate your improvement?
- What symptoms have improved?
- What symptoms do you still have?
_
5. What changes have been made in the following areas? Please indicate by using
I=Improved, S=same, or W= worse.
Sleep Bowel Movements Sinus Drainage ________
Stress Eating Habits Mental Fog __
Pain Exercise Habits ______ Dental Issues __
Digestion ______ Water Intake
- Is there any other condition you have that we have not covered that you now wish to go into?
If yes, please explain
- Is there any confusion or question about any phase of your progress?
- Has anyone asked about your progress? Yes No
- Have you referred anyone for wellness care? Yes No
If yes, would you like us to contact them for a courtesy consultation? (Please write their name, address & phone number.)
______
Patient’s Signature
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