Day One Questionnaire

Welcome to ChiroWay!

On this first visit, we will:

Answer any and all questions you have and ask questions for you to answer so we can get to know you better.
Review and sign our terms and conditions that will disclose the scope of our practice at ChiroWay.
Review and sign our informed consent that will disclose the responsibilities of the chiropractor, limitations of chiropractic, reasonable benefits to be expected and risks associated with care.
Review and sign our privacy policy that discloses how health information about you may be used.
Orientate you to our philosophy that is the foundation to the benefits of each chiropractic adjustment.
Prove a chiropractic evaluation, adjustment and presents report of findings and recommendations on how to best benefit from our services.
Conclude with finding the right membership plan for you.

To start, please fill out this brief questionnaire. These questions will help us get to know you, your health background and where you're at in your understanding of chiropractic care and our services at ChiroWay. Please fill out each answer to the best of your knowledge.

Full Name

What's motivating you to be here today?

Pain Relief

Promote Greater Wellbeing

Improve Current State of Health

Strengthen Performance

Increase Resistance to Stress

Does this motivation differ from what you've felt in past attempts to change your health?

Yes

None

Are you interested in a short-term goal or a long-term goal?

Short-Term

Long-Term

None

Are you open to having a long term transformation goal?

Yes

None

I live an eco-friendly lifestyle (for example, buying local food or turning the lights off).

Never

Rarely

Sometimes

Usually

Always

None

I eat nutritious meals that fuel my body and give me energy for the day.

Never

Rarely

Sometimes

Usually

Always

None

I exercise on a regular basis.

Never

Rarely

Sometimes

Usually

Always

None

I receive regular chiropractic care.

Never

Rarely

Sometimes

Usually

Always

None

I'm able to find the time to maintain good relationships with the people I care about.

Never

Rarely

Sometimes

Usually

Always

None

I'm optimistic about achieving my academic or career goals.

Never

Rarely

Sometimes

Usually

Always

None

I have a sense of peace and well-being about my life.

Never

Rarely

Sometimes

Usually

Always

None

I live an eco-friendly lifestyle (for example, buying local food or turning the lights off).

Never

Rarely

Sometimes

Usually

Always

None

I value self-discovery and self-improvement.

Never

Rarely

Sometimes

Usually

Always

None

I can recognize and manage stressors in my life.

Never

Rarely

Sometimes

Usually

Always

None

Do you understand regular chiropractic care may enhance nerve communication throughout the body?

Yes

None

Do you understand misalignments of the vertebrae, which interfere with the function and performance of the nerve system are called vertebral subluxation?

Yes

None

Do you know the objective of your ChiroWay Chiropractor is the evaluation and adjustment of vertebral subluxation?

Yes

None

Do you know chiropractic care at ChiroWay is offered for newborns, infants, children and teenagers?

Yes

None

Do you understand that misalignments of the bones of the spine which interfere with the neurological function are called vertebral subluxation?

Yes

None

Do you understand that vertebral subluxation are caused by everyday physical, chemical and emotional stress?

Yes

None

Do you understand that the objective at ChiroWay is to provide a chiropractic adjustment to correct vertebral subluxation thereby restoring normal nerve function to enhance your overall wellbeing?

Yes

None

Please press the SUBMIT button below to compete this questionnaire.

Time's up