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Wellness Check-In
Banora Chiropractic — Phase 3
Phase 3
Wellness & Maintenance Check-In
Monitor your long-term health and spinal wellness. Enter your name to begin.
Your full name
Returning patient — tap to continue:
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Spinal Health
Step 1 of 4
Phase 3
Step 1 — Spinal Health
25%
How is your spine feeling?
Monitoring your ongoing spinal comfort
Overall spinal comfort (0–10) —
8
/10
0 — Very uncomfortable
10 — Excellent
Any new areas of discomfort? (select all)
Neck
Upper back
Lower back
Shoulders
Hips
Headaches
None — all good
If discomfort, how long does it last?
No discomfort
A few minutes
A few hours
Most of the day
Constant
Compared to before chiropractic care:
Much better
Somewhat better
About the same
Somewhat worse
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🏃
Lifestyle & Habits
Step 2 of 4
Phase 3
Step 2 — Lifestyle
50%
Your lifestyle habits
Habits that support long-term spinal health
Daily sitting time
Less than 4 hours
4–6 hours
6–8 hours
More than 8 hours
Exercise frequency
Daily
4–5 days/week
2–3 days/week
Once a week
Rarely
Home exercises / stretches
Daily
Most days
Occasionally
Rarely
Workstation / ergonomics
Well set up
Fairly good
Needs improvement
Poor
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Stress, Sleep & Wellbeing
Step 3 of 4
Phase 3
Step 3 — Wellbeing
75%
Mental & overall wellbeing
Whole-person health matters
Stress level —
4/10
Low
High
Main stress sources (select all)
Work
Family
Financial
Health concerns
None — low stress
Sleep quality
Excellent
Good
Fair
Poor
Energy levels
High — feeling great
Good
Moderate
Low — often tired
Overall mood
Great
Good
OK
Low / struggling
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Prevention & Goals
Step 4 of 4
Phase 3
Step 4 — Prevention
100%
Prevention & future health goals
Staying proactive about your health
Confidence in maintaining your health —
8/10
Low
High
Active healthy habits (select all)
Regular stretching
Walking daily
Strength training
Mindfulness
Good sleep hygiene
Healthy eating
Ergonomic workspace
Overall health satisfaction (1–5)
Health goals for the next 3–6 months
Any notes for your chiropractor?
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Wellness Report
Check-in complete
Phase 3
⏳ Sending to clinic...
—
Overall Wellness Score
Summary
🖨️ Print / Save PDF
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