Perron Chiropractic

Patient Form

Please take a moment to share how you’re feeling and any changes you’ve noticed.

Patient Progress Assessment Form

This form helps us track your progress, assess your improvements, and fine-tune your care plan. Your feedback ensures we continue providing the best care tailored to your needs. Please take a moment to share how you’re feeling and any changes you’ve noticed.

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Name *

First

Last

Date *

Email *

What changes in your condition have you noticed since beginning care? *

On a scale of 1-10, rate the level of improvement for symptoms since beginning care: *

1 - No Change
2
3
4
5
6
7
8
9
10 - Condition Resolved

Describe any new condition that has developed since beginning care: *

Would you say your improvement is: *

Progressing at the speed you expected
Taking longer than you expected
Occurring much faster than you expected

Is there anything you do not understand about your condition or treatment? *

If yes, please explain:

Do you think you understand the difference between temporary care vs. wellness care? *

How would you rate the concern shown by our staff? *

1 - Uninterested
2
3
4
5
6
7
8
9
10 - Deeply Concerned

How would you rate the training, qualifications, and competency of our staff? *

1 - Unorganized/Unprepared
2
3
4
5
6
7
8
9
10 - Efficient/Knowledgeable

What do you like most about our office? *

Have you ever had any trouble scheduling an appointment with Dr. Perron? *

If yes, please explain:

Have we always answered your call during regular office hours? *

Yes
No
Not Sure

Is the amount of time you wait to see Dr. Perron acceptable? *

Are there any office or procedural changes you would suggest to improve our quality of care? *

changes ever beginning

What kinds of comments have you heard from your friends or family when you've told them about seeing a chiropractor? *

Referral Inquiry: *

I have referred family or friends to this office
I would gladly refer family or friends to this office
I would not refer family or friends to this office

Please list anyone you would like to refer | Include their full name, relation, and condition.