Retest Questionaire

BODY SCAN RETEST PROGRESS QUESTIONNAIRE

 

 

Name                                                                                             Date                                        

 

1. How do you classify your improvement so far since beginning your care?
               Excellent                     Good                       Fair                         Poor           

    

2. On a scale of 1 to 10, with 10 being the best, how would you rate your improvement?                    

    

3. What symptoms have improved?                                                                                                    
                                                                                                                                                        
                                                                                                                                                        

    

4. 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                                                    

 

6.  Is there any other condition you have that we have not covered that you now wish to go into?
   If yes, please explain                                                                                                                      
                                                                                                                                                        
                                                                                                                                                        
                                                                                                                                                        

 

7. Is there any confusion or question about any phase of your progress?
                                                                                                                                                        
                                                                                                                                                        
                                                                                                                                                        
   
   
8. Has anyone asked about your progress?           Yes                              No                  

 

9. 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