Questionnaire

Dr Jenna | Network Care Practitioner

Name
First Last
Date
MM slash DD slash YYYY
Date of previous evaluation:
MM slash DD slash YYYY
Please answer all questions in reference to when you first began care in this office, or to your last full re-evaluation, if applicable.
1. I am (more, same, less) aware of my spine. This awareness is especially noticeable (at work, at rest, standing, sitting, walking, moving).
2. This awareness (is, is not) a result of greater discomfort or pain.
3. {If the answer to #2 is yes} I am (aware, not aware) of what positions or movements of the spine bring about this awareness. They are:
4. I am (aware, not aware) of spinal tension and restricted movement independent of pain during my day.
5. I am (aware, not aware) of an increase in pleasant sensations or ease in my spine. These are:
6. I am (aware, not aware) of changes in the way I carry my body. These are:
7. I am (more, same, less) aware of my breathing when I am entrained.
8. I am (more, same, less) aware of my breathing in between entrainment sessions.
9. In general, my breathing is (deeper, same, more shallow) and (easier, same, more difficult).
10. In general, I (have, do not have) greater ease in standing straighter
11. In general, I (feel, do not feel) my spine or areas of my spine to be more at peace
12. In general, movement is (easier, same, more difficult)
13. I am (more aware, same, less aware) of where I hold tension in my body or spine.
14. I am (more aware, same, less aware) of when my body holds tension.
15. I am (more aware, same, less aware) of what releases tension from my body.
16. My body is becoming (more effective, same, less effective) at releasing its tension.
17. I (have, have not) experienced spontaneous movements in a part of my spine when another region was contacted during entrainment.
18. I (have, have not) experienced my body trying to unwind its tension while being adjusted.
19. I (have, have not) experienced a deeper awareness of knowing exactly what my body wants me to do. This has come in the area of: (rest, exercise, sleep, movement, etc.)
20. I (have, have not) been more able to listen to my body’s needs.
21. I have experienced the following additional marked mental, emotional, chemical and physical stresses during this period, in addition to those I listed on the last questionnaire I filled out.
22. I have had the following major relationship, job, residence or other life changes during this period:
23. I have professionally seen other doctors or therapists since I last completed a questionnaire from this office:
- Yes
- No
Please list information about the reason for the visit and any treatments or clinical determinations that were made:
24. I (have, have not) changed my dietary habits. Explain:
25. I (have, have not) begun or modified an exercise program. Explain:
26. I (have, have not) participated in classes or programs to enhance my healing capacity. Explain:
27. Use this space to write about anything else you would like to discuss with your Network Care practitioner about your spinal progress at this point in care.
Comments
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Questionnaire

Please answer all questions in reference to when you first began care in this office, or to your last full re-evaluation, if applicable.

Dedicated Support Team