Re-Examination Assessment Form

Our goal is to offer the very highest quality client care. Please help us by responding to these questions about your progress. Changes often happen quickly during care as your body begins the natural healing process.

First name

Birthday

Month

Day

Year

Phone

Email

Previous Care

What changes have you noticed since beginning care?

Positive Changes

Negative Changes

Would you say your improvement is:

Progressing at the speed you expected?

Taking longer than you expected?

Occurring much faster than you expected?

Is there anything else you would like me to know?

Consent to Treatment

I understand that with any healing process and work on my body, my symptoms may worsen before they get better.

I understand this care is designed to assist the body with healing by helping to remove stressors from the body. I understand that healing takes time and there is no quick immediate fix to my problem, and health is a process.

I have freely decided to undergo the recommended treatment adhere give my full consent to treatment.

Signature

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Date

Month

Day

Year