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Putney Health Refocus

Although we have known you a long time, we know how important it is to appreciate all we have, and to make sure you are happy and that we are meeting your needs!

Help us to serve you better by letting us know where your health is currently, and by letting us know how else we can help.

Personal Details *This question is required.

First Name
Surname
Date of Birth
Today's Date

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

1 being poor/low and 10 being outstanding/high. *This question is required.

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 & flus *This question is required	Immune system function/Recovery from colds & flus: 1 Poor/Low	Immune system function/Recovery from colds & flus: 2	Immune system function/Recovery from colds & flus: 3	Immune system function/Recovery from colds & flus: 4	Immune system function/Recovery from colds & flus: 5	Immune system function/Recovery from colds & flus: 6	Immune system function/Recovery from colds & flus: 7	Immune system function/Recovery from colds & flus: 8	Immune system function/Recovery from colds & flus: 9	Immune system function/Recovery from colds & flus: 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)	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

What is your understanding of what chiropractic is doing to improve your health?

Is there any way we can help you to understand more? (all feedback is appreciated!) *This question is required.

What aspects of your health are you 100% happy with and what should we focus on moving forward? *This question is required.

How would you like your body to move/feel that is different to now? *This question is required.

What are some of the health changes you have noticed compared to three months ago? *This question is required.

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

Comments:

How would you describe chiropractic to a friend or family member? *This question is required.

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

Would you like any specific information to help educate yourself further in regards to your health? *This question is required.

We would welcome your thoughts on the following aspects of your experience with us:

1 being low/poor
10 being high/outstanding *This question is required.

Space Cell	1	2	3	4	5	6	7	8	9	10
Doctors explanation of your health status	Doctors explanation of your health status: 1	Doctors explanation of your health status: 2	Doctors explanation of your health status: 3	Doctors explanation of your health status: 4	Doctors explanation of your health status: 5	Doctors explanation of your health status: 6	Doctors explanation of your health status: 7	Doctors explanation of your health status: 8	Doctors explanation of your health status: 9	Doctors explanation of your health status: 10
Doctors availability/opening hours	Doctors availability/opening hours: 1	Doctors availability/opening hours: 2	Doctors availability/opening hours: 3	Doctors availability/opening hours: 4	Doctors availability/opening hours: 5	Doctors availability/opening hours: 6	Doctors availability/opening hours: 7	Doctors availability/opening hours: 8	Doctors availability/opening hours: 9	Doctors availability/opening hours: 10
Doctors explanation of recommendations	Doctors explanation of recommendations: 1	Doctors explanation of recommendations: 2	Doctors explanation of recommendations: 3	Doctors explanation of recommendations: 4	Doctors explanation of recommendations: 5	Doctors explanation of recommendations: 6	Doctors explanation of recommendations: 7	Doctors explanation of recommendations: 8	Doctors explanation of recommendations: 9	Doctors explanation of recommendations: 10
Ability to provide you with enough information	Ability to provide you with enough information: 1	Ability to provide you with enough information: 2	Ability to provide you with enough information: 3	Ability to provide you with enough information: 4	Ability to provide you with enough information: 5	Ability to provide you with enough information: 6	Ability to provide you with enough information: 7	Ability to provide you with enough information: 8	Ability to provide you with enough information: 9	Ability to provide you with enough information: 10
Assistants administrative assistance	Assistants administrative assistance: 1	Assistants administrative assistance: 2	Assistants administrative assistance: 3	Assistants administrative assistance: 4	Assistants administrative assistance: 5	Assistants administrative assistance: 6	Assistants administrative assistance: 7	Assistants administrative assistance: 8	Assistants administrative assistance: 9	Assistants administrative assistance: 10
Assistants providing personable & friendly service	Assistants providing personable & friendly service: 1	Assistants providing personable & friendly service: 2	Assistants providing personable & friendly service: 3	Assistants providing personable & friendly service: 4	Assistants providing personable & friendly service: 5	Assistants providing personable & friendly service: 6	Assistants providing personable & friendly service: 7	Assistants providing personable & friendly service: 8	Assistants providing personable & friendly service: 9	Assistants providing personable & friendly service: 10
Assistant’s knowledge on queries	Assistant’s knowledge on queries: 1	Assistant’s knowledge on queries: 2	Assistant’s knowledge on queries: 3	Assistant’s knowledge on queries: 4	Assistant’s knowledge on queries: 5	Assistant’s knowledge on queries: 6	Assistant’s knowledge on queries: 7	Assistant’s knowledge on queries: 8	Assistant’s knowledge on queries: 9	Assistant’s knowledge on queries: 10
Value for service provided	Value for service provided: 1	Value for service provided: 2	Value for service provided: 3	Value for service provided: 4	Value for service provided: 5	Value for service provided: 6	Value for service provided: 7	Value for service provided: 8	Value for service provided: 9	Value for service provided: 10
Consistency on providing a warm, friendly environment	Consistency on providing a warm, friendly environment: 1	Consistency on providing a warm, friendly environment: 2	Consistency on providing a warm, friendly environment: 3	Consistency on providing a warm, friendly environment: 4	Consistency on providing a warm, friendly environment: 5	Consistency on providing a warm, friendly environment: 6	Consistency on providing a warm, friendly environment: 7	Consistency on providing a warm, friendly environment: 8	Consistency on providing a warm, friendly environment: 9	Consistency on providing a warm, friendly environment: 10

Please feel free to pass comment on your overall experience.

As a long standing client we value your opinion highly and are always looking for ways to improve your experience.

What do you like, what could you see us improve? *This question is required.