Doctor’s Chiropractic Report of Findings & Recommended Action Plan

Name: ______Date:______

Question 1- Can You help me?

Answer: Congratulations! Yes, we can help you.

Please review the Subluxation Nerve Chart for a better understanding of the devastating effects of nerve interference.

Your recommendations for chiropractic care are based on your initial evaluation which revealed…

_____Trauma(s) from your health history______

_____Symptom(s) relating to possible vertebral subluxation______

_____Normal spinal alignment/motion upon palpation

_____Spinal Kinesiopathology: Abnormal alignment and motion.

_____Normal EMG (electromyography)

_____Myopathology: Abnormal EMG levels.

_____Normal alignment on radiograph analysis

_____Pathophysiology: Spinal decay/aberrant alignment.

Notes

Question 2- How long will it take?

Answer: Research indicates that it may take from 9 to 18 months of consistent chiropractic care for the body to restore and stabilize the damaging effects of a Vertebral Subluxation.

Question 3 – How often do I need to receive care?

Answer: Your Recommended Action Plan is:

_____ Temporary pain relief: Schedule appointments daily until pain subsides or you reach your personal goal.

_____ Restoration care: Initial Intensive care plan _____ per week x _____ weeks

_____ per week x _____ weeks

Then Progress Analysis to determine the frequency for your future care.

Manual Therapy _____ per week x _____ weeks

Therapeutic Ex/Rehab _____ per week x _____ weeks

Spinal Supports Neck Back ______

Notes

If you follow your appointment schedule you will achieve the best possible results.

If you don’t, you won’t.

Question 4- How much will it cost me?

Answer: Choose your preferred method of payment.

1 Health Insurance 2 Work Related 3 Auto Injury 4 Payment per visit 5 Block Visits 6 Savings Plan

Benefits______details enclosed

______100% Coverage 100%Coverage see posted fee’s 15 visits=$742 monthly pmt

______30 visits=$1155 annual payment

______

Thank you for the opportunity to serve you. If you have additional questions or concerns,

please feel free to discuss them with the doctor or our staff so that we may ensure your satisfaction.

Your Office Name, Address, Phone number and website here

© 2008 Discover Wellness Inc.