Welcome to Johnson
Chiropractic
(619) 464-3333
Today we
are here to discover your goals and priorities as it relates to your health and
wellness. Your answers will help us determine how we may best serve you.
Let’s get
started…
Name: ____________________________________
Date:__________
How would you best describe your
level of interest in wellness?
_______ Not
very interested in wellness
_______ Curious
about wellness
_______ Interested
in greater health and wellness
On a scale of 1 to 10, rate the importance for you to
achieve the following:
1 = not important, 10 = absolutely
necessary
Get fit 1
2
3 4 5 6 7
8 9 10
Eat Better 1 2
3 4 5
6 7 8
9 10
Reduce Stress 1 2
3 4 5
6 7 8
9 10
Reduce Pain 1 2
3 4 5
6 7 8
9 10
Increased
Mobility 1 2
3 4 5
6 7 8
9 10
Improved Posture 1 2
3 4 5
6 7 8
9 10
Improved Sleep 1 2
3 4 5
6 7 8
9 10
Learn About
Wellness 1 2
3 4 5
6 7 8
9 10
Learn About
Wellness Products 1 2
3 4 5
6 7 8
9 10
Other
__________________ 1 2
3 4 5 6
7 8 9
10
Of the above, what would you say is the most
important goal for you to achieve and why?
______________________________________
Have you ever attempted to accomplish this goal in
the past? Yes or No
- If
yes, what happened and what prevented you from maintaining your
results?
________________________________________________________
Remember: Your health is your
greatest asset. The more of it you have, the healthier you are. We look forward
to helping your Discover Wellness.
©2008 Discover Wellness Inc.