Name* First Last Date* Date Format: MM slash DD slash YYYY Phone*Do you have any questions or concerns at this point?*YesNoWhat are your questions or concerns?*How would you rate your progress thus far?*PoorFairGoodSignificantExcellentWhat level of improvement have you seen in your health and/or symptoms?*WorseNoneMildNoticeableExcellentHow would you rate the staff's response to your concerns?*PoorFairGoodSignificantExcellentHow would you rate the practitioner's response to your concerns?*PoorFairGoodSignificantExcellentAre you up to date on reading your program documents?*YesNoIf no, please explain why:Have you implemented a regular exercise routine?*YesNoIf no, please explain why:Have you kept on schedule with the program?*YesNoIf no, please explain why:Rate your overall participation level up to this point in the program*(1 is lowest, 10 is highest)Please enter a number from 1 to 10.Please share some of the results you have achieved thus far on the program:*What improvements to the program would you suggest at this point?*