Quality of Life Survey

Patient Quality Of Life Survey

Name: *

Date: *

Please take several minutes to answer these questions so we can help you get better.

(Please check as many that apply)

How have you taken care of your health in the past? *

Medications Emergency Room Routine Medical Exercise Nutrition/Diet Holistic Care Vitamins Chiropractic

How did the previous method(s) work out for you? *

Bad results Some results Great Results Nothing changed Did not get worse Did Not work very long Still trying Confused

How have others been affected by your health condition? *

No one is affected Haven't Noticed any problem They tell me to do something People avoid me

What are you afraid this might be (or beginning) to affect (or will affect)? *

Job Kids Future Ability Marriage Self esteem Sleep Time Finances Freedom

Are there health conditions you are afraid this might turn into? *

Family health condition Heart disease Cancer Diabetes Arthritis Fibromyalgia Depression Chronic Fatigue Need Surgery

How has your health condition affected your job, relationships, finances, family, or other activities? Please give examples: *

What has that cost you? (time, money, happiness, freedom, sleep, promotion, etc.) Give 3 examples: *

What are you most concerned with regarding your problem? *

Where do you picture yourself being in the next 1-3 years if this problem is not taken care of? Please be specific *

What would be different/better without this problem? Please be specific *

What do you desire most to get from working with uS? *

What would that mean to you? *