Your Recommendations Are Based On

Name:______Date:______

The purpose of today’s visit is to review my best recommendations for your care. In order to optimize your care plan it will be important for you understand these recommendations and take responsibility for your care. Your results will be directly proportional to the amount of effort you put forth.

Your recommendations are based on:

( ) The three areas of Lifestyle stress:

Physical Bio-chemical Psychological

1. ______1. ______1. ______

2. ______2. ______2. ______

3. ______3. ______3. ______

4. ______4. ______4. ______

( ) Insight Subluxation Findings

COREscore+ = ______

( ) Subluxations analyzed on X-Ray Film

( ) Phase of Subluxation Degeneration

Neck: I II III Normal

Low Back: I II III Normal

( ) Restricted Motion of your spine

( ) Your age and health history

( ) Current Level of Health and Wellness

[ ]Excellent [ ]Good [ ]Transition

[ ]Challenged [ ]Very Challenged

Recommendations:

Based on your health goals, I am recommending a minimum of 2-4 4-6 6-8 8-12 12+ months of chiropractic care to get your nervous system functioning at a healthier level.

This is approximately _____to_____ visits.

We will see you _____x’s per week for _____week(s) and then ______x’s per week.

We will re-evaluate you every 4 6 8 10 12 14 visits to closely monitor your progress.

Getting the most of your care program:

1. Follow our recommendations, as we are YOUR health and wellness coaches. Follow the plan and you can experience magnificent results.

2. Utilize our Multiple Appointment Program. By making multiple appointments you will save yourself time and insure that your time slot is reserved.

3.Attend the required New Patient Orientation.

4.Get your family checked for Subluxation.

5.Ask Questions. If you have questions or if something is not clear, please let us know. It’s your health and we want to do all we can to help you benefit the most from your program.