Patient Re-Evaluation


Congratulations on this progress evaluation! These exams are like mile markers on your road to

optimal health. Together through education we can change the lives of our community.

Help us Re-Evaluate Your Health

Is this due to a:
The overall severity of your complaints/concerns is:
The overall frequency is:
If your symptoms change, when are they worse:
Are your symptoms/pain getting:
Do you have any additional complaints/concerns/health problems?
Draw over image
If your complaints include pain, how would you describe it? (please check all that apply):
Since your symptoms began, have you noticed any function changes
Do work activities aggravate your present complaints?

Your Current Health Status

Please let us know if we need to be mindful of the following:

Drinking coffee or tea can excite the nervous system. Have you had any of these caffeinated beverages today?
Nicotine is a nervous system stimulant. Have you used any tobacco today?
Common over-the-counter drugs can impact the nervous system. Have you taken any of these types of drugs today?
Many Prescription drugs and muscle relaxers affect the nervous system. Have you taken any prescription medication today?
Excessive exposure to sun & tanning bed use, affects the accuracy of your scan. Have you had a sunburn in the last 5 days?
Bath salts, oils or sunscreens on your skin can influence instrument sensitivity. Have you used any of these products today?
Vigorous physical activity can exaggerate your scan results. Have you had a workout today?
Stress, depression, anxiety or emotional upsets can affect nervous system tension. Compared to a typical day, are you currently experiencing any type of emotional trauma?

We hope your experience with our office has been a pleasant one and

If there is anything that we could do to make the experience better please let us know.

Thank you for taking the time to fill out this form.

Newsletter Sign Up!

Our Location

2846 Garber Way | Woodbridge, VA 22192

Office Hours

Our General Schedule


9:00 am-12:00 pm

3:00 pm-6:30 pm


9:00 am-12:00 pm

3:00 pm-6:00 pm


3:00 pm-6:00 pm


9:00 am-12:00 pm

3:00 pm-6:30 pm