Berkeley Progress Review

Please take 5 minutes to fill in the following reassessment.

This will help us to look after you as best we can and ensure we continue to make progress in getting you to optimal health and vitality.

Personal Details

*This question is required.

	Todays Date
	First Name
	Surname
	Date of Birth

Please rate your level of satisfaction in the following health related areas -

1 being poor/low and 10 being outstanding/high.

Space Cell	1 poor/low	2	3	4	5	6	7	8	9	10 Outstanding/High
Flexibility *This question is required	Flexibility: 1 poor/low	Flexibility: 2	Flexibility: 3	Flexibility: 4	Flexibility: 5	Flexibility: 6	Flexibility: 7	Flexibility: 8	Flexibility: 9	Flexibility: 10 Outstanding/High
Digestion *This question is required	Digestion: 1 poor/low	Digestion: 2	Digestion: 3	Digestion: 4	Digestion: 5	Digestion: 6	Digestion: 7	Digestion: 8	Digestion: 9	Digestion: 10 Outstanding/High
Energy levels *This question is required	Energy levels: 1 poor/low	Energy levels: 2	Energy levels: 3	Energy levels: 4	Energy levels: 5	Energy levels: 6	Energy levels: 7	Energy levels: 8	Energy levels: 9	Energy levels: 10 Outstanding/High
Mood *This question is required	Mood: 1 poor/low	Mood: 2	Mood: 3	Mood: 4	Mood: 5	Mood: 6	Mood: 7	Mood: 8	Mood: 9	Mood: 10 Outstanding/High
Sleep quality and feeling of being well rested upon waking *This question is required	Sleep quality and feeling of being well rested upon waking: 1 poor/low	Sleep quality and feeling of being well rested upon waking: 2	Sleep quality and feeling of being well rested upon waking: 3	Sleep quality and feeling of being well rested upon waking: 4	Sleep quality and feeling of being well rested upon waking: 5	Sleep quality and feeling of being well rested upon waking: 6	Sleep quality and feeling of being well rested upon waking: 7	Sleep quality and feeling of being well rested upon waking: 8	Sleep quality and feeling of being well rested upon waking: 9	Sleep quality and feeling of being well rested upon waking: 10 Outstanding/High
Ability to recover from stressful events *This question is required	Ability to recover from stressful events: 1 poor/low	Ability to recover from stressful events: 2	Ability to recover from stressful events: 3	Ability to recover from stressful events: 4	Ability to recover from stressful events: 5	Ability to recover from stressful events: 6	Ability to recover from stressful events: 7	Ability to recover from stressful events: 8	Ability to recover from stressful events: 9	Ability to recover from stressful events: 10 Outstanding/High
Posture *This question is required	Posture: 1 poor/low	Posture: 2	Posture: 3	Posture: 4	Posture: 5	Posture: 6	Posture: 7	Posture: 8	Posture: 9	Posture: 10 Outstanding/High
Immune system function/Recovery from colds & Flu's *This question is required	Immune system function/Recovery from colds & Flu's: 1 poor/low	Immune system function/Recovery from colds & Flu's: 2	Immune system function/Recovery from colds & Flu's: 3	Immune system function/Recovery from colds & Flu's: 4	Immune system function/Recovery from colds & Flu's: 5	Immune system function/Recovery from colds & Flu's: 6	Immune system function/Recovery from colds & Flu's: 7	Immune system function/Recovery from colds & Flu's: 8	Immune system function/Recovery from colds & Flu's: 9	Immune system function/Recovery from colds & Flu's: 10 Outstanding/High
Exercise frequency *This question is required	Exercise frequency: 1 poor/low	Exercise frequency: 2	Exercise frequency: 3	Exercise frequency: 4	Exercise frequency: 5	Exercise frequency: 6	Exercise frequency: 7	Exercise frequency: 8	Exercise frequency: 9	Exercise frequency: 10 Outstanding/High
Overall health and feeling of vitality *This question is required	Overall health and feeling of vitality: 1 poor/low	Overall health and feeling of vitality: 2	Overall health and feeling of vitality: 3	Overall health and feeling of vitality: 4	Overall health and feeling of vitality: 5	Overall health and feeling of vitality: 6	Overall health and feeling of vitality: 7	Overall health and feeling of vitality: 8	Overall health and feeling of vitality: 9	Overall health and feeling of vitality: 10 Outstanding/High
Severity of any pain or symptom (if applicable) *This question is required	Severity of any pain or symptom (if applicable): 1 poor/low	Severity of any pain or symptom (if applicable): 2	Severity of any pain or symptom (if applicable): 3	Severity of any pain or symptom (if applicable): 4	Severity of any pain or symptom (if applicable): 5	Severity of any pain or symptom (if applicable): 6	Severity of any pain or symptom (if applicable): 7	Severity of any pain or symptom (if applicable): 8	Severity of any pain or symptom (if applicable): 9	Severity of any pain or symptom (if applicable): 10 Outstanding/High

If you originally consulted our practice for a pain or symptom please comment on any changes so far... *This question is required.

Please enter an 'other' value for this selection.

Comments

What are your present health motivations in working with us? (select one or more) *This question is required.

Simply pain relief
Pain relief and prevention of future problems
Optimal strength and flexibility of my frame
Optimal nervous system function
Optimal health and well-being
Optimal health and well-being for me and my whole family
Other Please enter an 'other' value for this selection. * This question is required.

Comments

What are your health focuses moving forward? *This question is required.

Please enter an 'other' value for this selection.
Please enter an 'other' value for this selection.

Comments

Do you want to continue working together? *This question is required.

Comments

Do you have any further questions or anything you would like to pass on to your practitioner?

Would you like any specific further information to educate yourself further in regards to your health?

We would love to know if we are doing a good job of educating you about what is going on with your body.

Could you explain what we are working on with you, or, how you would describe chiropractic to a friend or family member?

Berkeley Progress Review

All about you...