12th visit questinnaire
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This document is a 12 visit patient questionnaire from Romford and Ilford Family Chiropractic asking patients about their experience receiving chiropractic care. The questionnaire contains 9 questions asking patients how they heard about the practice, the health conditions that prompted their visit, what they learned caused their problem, their results, how treatment has changed their life, how they plan to use chiropractic in the future, who they would recommend it to, if other family members have received care, and a section for additional comments.
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12th visit questinnaire
- 1. Romford & Ilford Family Chiropractic Ltd Tel: 0208 252 1010 313 High Road, Chadwell Heath Romford, Essex RM6 6AX www.chiropracticcare.co.uk 12 Visit Patient Questionnaire At Romford and Ilford Family Chiropractic it is important to the entire team to know that our patients are well cared for by the Doctors of Chiropractic and management staff alike. Therefore we would appreciate it if you could kingly take a moment to answer the following questions and feel free to add any further comments. 1. How did you hear about our practice? ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… 2. What health conditions prompted you to see us? ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… 3. What did you learn was the cause of your problem? ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… 4. What were your results? ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… 5. How has it changed your life? ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… 6. How do you see yourself using chiropractic care in the future? ……………………………………………………………………………………………… ……………………………………………………………………………………………… ………………………………………………………………………………………………
- 2. 7. Who would you recommend chiropractic to? ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………… 8. Who in your family has received a check up? ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………… 9. If you have any further comments, please make a note in the space provided. ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………… We would like to thank you for taking the time to answer our questions. Once completed please place into the ‘completed questionnaire’ box in the reception area. Thank you..