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Subsequent Session Preparation
- Review Questionnaire -

Fill in your review questionnaire monthly.

If you prefer a paper form to the digital version, you will find one on the Questionnaires Page to print and bring with you on the day.

(Please note, consent to clinic-only information collection is implied by filling in and submitting the form. We store all personal information safely and securely, for private one-on-one consultation use only.)

Treatment Review Questionnaire

Please help us understand how your health and wellness has changed since beginning treatment.

Full Name

Email address

What is the focus of your next session / series?

What positive changes have you noticed since starting treatment?

What challenges have you experienced during treatment?

Have you started, stopped or changed any medications? What are you currently taking and what time of day and dose?

Have you started, stopped or changed any supplements? What are you currently taking and what time of day and dose?

Overall, how would you rate your improvement since starting treatment?*

Significant improvement

Moderate improvement

Slight improvement

No change

Slight worsening

Moderate worsening

Significant worsening

Rate your current energy levels (1-5 stars)*

Rate your current sleep quality (1-5 stars)*

Please provide details about your sleep patterns

Include information about sleep duration, quality, difficulty falling asleep, staying asleep, and any sleep disturbances

Rate your current mood and mental wellbeing (1-5 stars)*

How have these emotional states changed since treatment? (Select all that apply)

Grief - improved

Grief - worsened

Anger - improved

Anger - worsened

Frustration - improved

Frustration - worsened

Restlessness - improved

Restlessness - worsened

Please say more about any emotional changes

Rate your current physical pain levels (1-5 stars, 1 = severe pain, 5 = no pain)*

How has your movement and mobility changed since treatment?*

Significantly improved

Moderately improved

Slightly improved

No change

Slightly worsened

Moderately worsened

Significantly worsened

Which musculoskeletal symptoms have changed? (Select all that apply)

Joint stiffness - improved

Joint stiffness - worsened

Muscle pain - improved

Muscle pain - worsened

Back pain - improved

Back pain - worsened

Neck pain - improved

Neck pain - worsened

Range of motion - improved

Range of motion - worsened

Other musculoskeletal changes

Please elaborate on any musculoskeletal changes

Which symptoms have improved since treatment? (Select all that apply)

Fatigue

Sleep problems

Anxiety

Depression

Physical pain

Digestive issues

Headaches

Concentration problems

Stress levels

Mobility issues

Grief

Anger

Frustration

Restlessness

Other improved symptoms

Please elaborate

Which symptoms are still concerning you? (Select all that apply)

Fatigue

Sleep problems

Anxiety

Depression

Physical pain

Digestive issues

Headaches

Concentration problems

Stress levels

Mobility issues

Grief

Anger

Frustration

Restlessness

Other ongoing concerns

Please elaborate on any ongoing symptoms / experiences

What health and lifestyle changes have you made since starting treatment?

Include changes to diet, exercise, sleep habits, stress management, work-life balance, etc.

What have you successfully implemented from your treatment plan / session learnings?

What recommendations are you yet to implement?

How satisfied are you with your treatment progress?*

Very satisfied

Satisfied

Neutral

Dissatisfied

Very dissatisfied

Are you able to perform daily activities better than before treatment?*

Much better

Somewhat better

About the same

Somewhat worse

Much worse

Would you recommend this treatment to others with similar conditions?*

Definitely yes

Probably yes

Not sure

Probably no

Definitely no

What additional support or changes would help improve your progress?

Are you seeing any other practitioners are you currently seeing and what is it for?

Have you had any tests or scans?

Is there anything else you would like to add about your progress, symptoms, experiences or forward plans for your upcoming session/s?

PRIVACY CONSENT - Just letting you know that your info is used to respond to your enquiry and manage appointments. We use secure industry-compliant AI-assisted clinical management systems to keep your information safe. See our Privacy Policy for more.

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Heart healing

HEALTHIER

By Choice

Monica Williams - Healthier by Choice

Maroochydore, Queensland

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