Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name: *FirstLastHave you noticed any SYSTEMS of the body functioning better since your subluxations have been reduced? Check all that apply:RespiratoryMuscular / SkeletalNervous SystemReproductiveDigestiveSkinBrain FunctionVascularOtherPlease check ALL of Chiropractic Miracles that you have already experienced since the beginning of your care:Improved digestionMore regular/comfortable cyclesImproved thyroid functionImproved sexual function/fertilityPositive mood changesImproved sleep/energyReduced prostate irritationImproved sexual function/fertilityReduced acid refluxImproved digestionLess stressImproved balanceImproved coordinationImproved memoryImproved visionImproved hearingImproved behaviourImprovement with colic (CHILD)Improvement with earaches (CHILD)Improvement with bed-wetting (CHILD)Better grades (CHILD)Asthma/allergies relieved (CHILD)Please grade how well you have been doing with keeping your adjustment schedule: Selected Value: 0 Please grade how well you have been doing with doing home exercises: Selected Value: 0 Please grade how well you have been doing with breaking bad habits: Selected Value: 0 On a scale of 0 to 10, how important is it for you to complete your care plan including Chiropractic Wellness Care and keep from losing your results so far? Selected Value: 0 In your own words, why is Chiropractic wellness care so important for you?What do you hope to get out of your wellness care?Retain current resultsGet Even BetterPrevent SubluxationsPrevent Degeneration/ArthritisGet StrongerMore EnergyBeing More RelaxedBetter BalanceBeing Less Nervous/AnxiousBetter SleepImproved DigestionSubmit
