2020 wellbeing check

First and last name *This question is required.

Email *This question is required.

Date of birth *This question is required.

Your preferred clinic location *This question is required.

Your main chiropractor *This question is required.

1. Please rate out of 10 your general level of health and well-being in 2010 and now in 2020.

Space Cell	1 Unhealthy	2	3	4	5	6	7	8	9	10 Healthy and well
Health rating in 2010	Health rating in 2010: 1 Unhealthy	Health rating in 2010: 2	Health rating in 2010: 3	Health rating in 2010: 4	Health rating in 2010: 5	Health rating in 2010: 6	Health rating in 2010: 7	Health rating in 2010: 8	Health rating in 2010: 9	Health rating in 2010: 10 Healthy and well
Health rating in 2020	Health rating in 2020: 1 Unhealthy	Health rating in 2020: 2	Health rating in 2020: 3	Health rating in 2020: 4	Health rating in 2020: 5	Health rating in 2020: 6	Health rating in 2020: 7	Health rating in 2020: 8	Health rating in 2020: 9	Health rating in 2020: 10 Healthy and well

2. Please elaborate on why your health is better or worse in 2020 compared to 2010

3. What is your health/life focus for 2020? 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 plant based, etc... Please enter an 'other' value for this selection.
Other.... Please enter an 'other' value for this selection.

Comments

4. 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	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	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	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	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	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	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	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	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	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	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
Satisfaction in the strength and function of your spine/back	Satisfaction in the strength and function of your spine/back: 1 poor/low	Satisfaction in the strength and function of your spine/back: 2	Satisfaction in the strength and function of your spine/back: 3	Satisfaction in the strength and function of your spine/back: 4	Satisfaction in the strength and function of your spine/back: 5	Satisfaction in the strength and function of your spine/back: 6	Satisfaction in the strength and function of your spine/back: 7	Satisfaction in the strength and function of your spine/back: 8	Satisfaction in the strength and function of your spine/back: 9	Satisfaction in the strength and function of your spine/back: 10 Outstanding/High

5. 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?

6. Thank you for completing this survey, please make comment on your overall experience with Chiro.London & Putney Chiro - what do you like, what would you like to see us improve?