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Phase 3: Wellness Care
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(203) 316-8477
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Book Appointment
Home
About Us
Dr. Brian Yomtov
Staff & Specialist
Testimonials
Office Athletic Team
Contact Us
Schedule an Appointment
Services
Chiropractic
Chiropractic Care During Pregnancy
Pediatric Chiropractic Care
Applied Kinesiology
Acupuncture
Acupuncture for Infertility
Dry Needling
Family Chiropractic
Family Chiropractic FAQs
The Complete Guide to Chiropractic Care for Families
The Role of Chiropractic Care in Preventing Common Family Health Issues
Massage
Additional Services
New Patient Center
What to Expect
Your First Visit
Phase 1: Relief Care
Phase 2: Corrective Care
Phase 3: Wellness Care
Payment Options
Store
Community Partners
(203) 316-8477
Progress Exam 1
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Progress Exam 1
Advanced Chiropractic & Wellness, LLC.
Progress Assessment I
First Name
*
Last Name
*
Today's Date
Initial Visit:
Undo
Clear
1.What was the original symptom or reason you visited the office?
2. How do you classify your improvement so far since beginning your care?
Excellent
Good
Fair
Poor
3. On a scale of 1 to 10 with 10 being the best, how would you rate your improvement?
4. What symptoms improved?
5. What symptoms do you still have?
6. What changes have been made in your general feelings? Are you: (check those indicated)
Stronger
More Relaxed
More Alert
Less Nervous
Sleep Better
Appetite Improved
7. Do you find it easier: (check those indicated)
Walking
Riding
Working
Bending
Standing
Sitting
Lifting
8. Are there any other conditions you have that you would like to discuss at this time? If yes, please explain:
9. Is there any confusion or question about any phase of your progress?
10. Do you intend to continue care to avoid problems in the future?
Yes
No
11. Would you like to learn more about any of the following: (check those indicated)
Acupuncture
Dry Needling
Cupping
Gua Sha
Nutritional Counseling
Kinesiotape
12. Your honest evaluation of our office is always appreciated. Please comment on any areas where we may improve.
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Thank you for taking the time to fill out this form.
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Office hours & location
Monday
12:30 PM — 8:00 PM
Tuesday
9:30 AM — 6:00 PM
Wednesday
7:30 AM — 1:00 PM
Thursday
9:30 AM - 8:00 PM
Friday
8:30 AM - 4:00 PM
Saturday
8:00 AM - 2:00 PM
Sunday
Closed
Our location
1150 Summer St
Stamford, CT 06905
(203) 316-8477
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We help individuals overcome pain and regain their mobility, providing personalized care solutions to help you get back to doing what you love quickly and effectively.
EXPLORE
Home
About Us
Dr. Brian Yomtov
Staff & Specialist
Testimonials
Office Athletic Team
Contact Us
Schedule an Appointment
Services
Chiropractic
Chiropractic Care During Pregnancy
Pediatric Chiropractic Care
Applied Kinesiology
Acupuncture
Acupuncture for Infertility
Dry Needling
Family Chiropractic
Family Chiropractic FAQs
The Complete Guide to Chiropractic Care for Families
The Role of Chiropractic Care in Preventing Common Family Health Issues
Massage
Additional Services
New Patient Center
What to Expect
Your First Visit
Phase 1: Relief Care
Phase 2: Corrective Care
Phase 3: Wellness Care
Payment Options
Store
Community Partners
OUR LOCATION
1150 Summer St
Stamford, CT 06905
(203) 316-8477
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