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Relief Care Check-In

Banora Chiropractic — Phase 1

Phase 1

Relief Care Progress

Track your progress during the relief care phase. Enter your name to begin.

Your full name

Returning patient — tap to continue:

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Pain Levels

Step 1 of 4

Phase 1

Step 1 — Pain Levels25%

How is your pain today?

0 = no pain, 10 = worst imaginable

Pain right now

0 — None10 — Worst

Worst pain since last visit

0 — None10 — Worst

Compared to your first visit, your pain has:

Significantly improved Somewhat improved About the same Somewhat worse Significantly worse

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Daily Function

Step 2 of 4

Phase 1

Step 2 — Daily Function50%

How are you functioning day-to-day?

Since starting treatment

Impact on daily tasks

Fully functional Mild impact Moderate impact Significant impact Cannot do most tasks

Impact on work

No impact Mild impact Moderate impact Significant impact Unable to work

Activities you've been able to return to (select all)

Walking Driving Work Exercise Household tasks Sport Social activities None yet

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Sleep & Wellbeing

Step 3 of 4

Phase 1

Step 3 — Sleep & Wellbeing75%

Sleep & mental wellbeing

How are you feeling overall?

Sleep quality this week

Good — sleeping well Fair Poor — woken by pain Very poor

Were you woken by pain this week?

No Yes — 1-2 nights Yes — most nights Yes — every night

Overall mood this week

Great — positive Good OK — managing Low / frustrated

Stress level — 5/10

LowHigh

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Treatment Feedback

Step 4 of 4

Phase 1

Step 4 — Feedback100%

How is treatment going?

Your feedback helps us adjust your care plan

Are you completing your home exercises?

Yes — every day Yes — most days Sometimes Not really No exercises given

How do you feel after adjustments?

Great — immediate relief Good — gradual improvement Some soreness then better Neutral — not sure yet Worse after — need to discuss

Overall satisfaction with care so far

Very satisfied Satisfied Neutral Unsatisfied — need to discuss

Any other notes for the chiropractor?

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Progress Report

Check-in complete

Phase 1

⏳ Sending to clinic...

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Overall Health Score — Relief Care

Summary