Standing Tall Chiropractic
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Health and Goals Questionaire
From Standing Tall Chiropractic: Creating Wellness Center, Glendale The most successful patient relationships have consistently started with the patient providing some basic information about their health and life goals. If you are interested in considering working together, a good first step is to answer the questions below.

Please fill out the questionaire below as completely as possible so we may get a clearer picture of your health development needs. Then send the information by clicking on the "Submit Questionaire" button at the bottom of the page. Thank you.

Name:  *Required
Address:  *Required
City:  *Required
Zip:  *Required
Phone:  *Required
Email:  *Required
   
1. List your major health challenges:
2. What have you tried in the past?
Drugs?
Surgery?
Chiropractic?
Physical Therapy?
Hypnosis?
Acupuncture?
Exercise?
Dieting?
Other?  

3. Which activities are the most effective now in terms of return on investment?


How do you know?

4. Which activities are the least effective now in terms of return on investment?


How do you know?
5. Rank your health on a scale of 1–10

10 >   (Incredibly Healthy)
6. Have you ever been in a health development program?

  
7. Imagine you had incredible health.  What would your life be like?
8. Are you looking for sustained health or band–aid care?

  
9.  On a scale of 1–10, how ready are you to invest in a health development system that will improve your overall health and quality of life?

10 >   (Ready Right Now)
 

If a question truly does not apply to you, feel free to skip it.
Thank you for completing this survey.
All information included will be considered confidential.


Standing Tall Chiropractic:
A Creating Wellness Center

3436 N. Verdugo Rd., Suite 250
Glendale, CA 91208

Tel: 818-249-WELL (9355)
Email: dr.dale@thedoctorofthefuture.com

 

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