Anderson Peak Performance – Initial Patient Survey

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It is our goal to clearly understand your objectives in seeking chiropractic health care. You can help us help you by answering the following brief questions:

Name: *

Email: *

Phone: *

Address:

City:

State:

Zip / Post Code:

1. My Current concept of health is:

Being pain free
Having all parts of my body functioning correctly
I've never really thought it though

2. My current understanding of chiropractic is:

Non-existent
Limited
Extensive

3. What i think is:

4. My attitude towards being here is:

Hopeful & interested
Neutral
Fearful
Leery & skeptical
Antagonistic - I don't really want to be here

5. The following is a brief description of what i anticipate will occur with chiropractic care. (If you have no idea, then simply state that.)

6. With my current understanding of chiropractic health care, my objective is:

Simply being pain free as soon as possible
Being pain free as soon as possible, but also stabilising my spine so that i experience improved health and freedom of movement
Pain free, stable and on a health maintenance program for a healthier future
I really have no idea. Ill let the doctor decide whats best