Patient Feedback & Testimonial Form - ACT

Detoxification Questionnaire

Please let us know how you found your experience with us by rating the following categories between values 1-5 (1 being poor and 5 being excellent) please circle your rating:

STAFF

ENVIRONMENT

TREATMENT PLAN

PATIENT SUCCESS

We routinely gather information from our patients on their experiences in receiving care at Newton Chiropractic and Wellness. In addition to helping us serve you better, we would like to use your responses to create a "book" of personal anecdotes for prospective patients about the benefits of pursuing "whole health" and seeking gentler forms of treatment, such as we offer here, before more invasive therapies are required. By sharing your story, you are helping others to understand some of the benefits derived from the techniques and services provided here. Accordingly, we would very much appreciate your candid responses to the following questions in a paragraph or two. We would love to use your name but, if you prefer, we will use your initials only. 

1. 
   In what ways has receiving care at Newton Chiropractic Centre benefited you?
   (We are particularly interested in "life changes" for the better – as examples, you
   can now turn your head fully to both sides, you are sleeping better, or you no
   longer need to take a certain medication…)
2. 
   What obstacles or challenges to receiving care have you encountered that you
   have had to overcome? (As examples, making time in a busy schedule, being sore
   after an adjustment or bodywork session, or having a persistent symptom that got
   worse before it got better.)
   
   
3. Did you experience any "surprise" benefits, learning, or other positive changes as a
   result of your care that you were not anticipating? (As examples, sleeping better,
   being able to handle stress better, or relief of an unrelated symptom, freedom
   from ongoing emotional pain.)