Synergy Chiropractic & Health Rehabilitation Centr
409 - 3950 14th Ave
Markham, ON L3R 0A9
905 479 3030
info@synergychiro.net
First Name
Last Name
Any new health concerns since last evaluation? 10 = best, 0 = worst
I would rate the overall movement and flexibility in my neck

Rigid
Flexible
I would rate the overall movement and flexibility in my mid back

Rigid
Flexible
I would rate the overall movement and flexibility in my low back

Rigid
Flexible
I am able to notice tension and release it in my body.

Not at All
I completely Notice
Overall posture & ease in standing straight?

Terrible
Great
I have good quality sleep and wake up feeling rested?

Tired
Rested
I have energy for all daily activities?

None
A lot
I have fewer illnesses and recover faster?

No
Yes
My exercise is

Terrible
Excellent