2015 wellbeing check

Date *This question is required.

First and last name *This question is required.

Email *This question is required.

Date of birth *This question is required.

What does 2015 hold for you, please help us to help you be healthier in 2015 by listing your areas of health focus this year? Please choose one or more and provide details....

Improved general health and vitality Please enter an 'other' value for this selection.
A family life event (wedding, pregnancy, etc...) Please enter an 'other' value for this selection.
A big sporting event (charity bike ride, more gym use, running marathon, triathlon, 5km walk...) Please enter an 'other' value for this selection.
A new job/career challenge Please enter an 'other' value for this selection.
Improved body image (posture, weight loss, etc...) Please enter an 'other' value for this selection.
Improved dietary habits (alcohol intake, more fresh vegetable, etc... Please enter an 'other' value for this selection.
Other.... Please enter an 'other' value for this selection.

Comments

Please rate your level of satisfaction in the following health related areas (1 being poor and 10 being outstanding).

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
Concern over a pain or symptom *This question is required	Concern over a pain or symptom: 1 poor/low	Concern over a pain or symptom: 2	Concern over a pain or symptom: 3	Concern over a pain or symptom: 4	Concern over a pain or symptom: 5	Concern over a pain or symptom: 6	Concern over a pain or symptom: 7	Concern over a pain or symptom: 8	Concern over a pain or symptom: 9	Concern over a pain or symptom: 10 Outstanding/High

Do you have any further questions or anything you would like to pass on to your practitioner? Would you like any specific information to help you along your optimal health journey?

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* Facebook Please enter an 'other' value for this selection.
Twitter Please enter an 'other' value for this selection.
Instagram Please enter an 'other' value for this selection.

Thank you for passing on this information. Please feel free to pass comment on your overall experience at Putney Chiropractic. What do you like, what would you like to see us improve?