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.
Phone
This field is for validation purposes and should be left unchanged.

Dedicated Support Team

Let's Connect!

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