PM&A practice development and marketing for chiropractors
 Free Stuff: Articles, Tips, & Tools

Subscribe to our
More Patients
Free eZine.

Email Newsletter icon, E-mail Newsletter icon, Email List icon, E-mail List icon

Free Stuff: Articles, Tips, & Tools

Patient Success Survey Form
Apr 14, 2006

Email this article
 Printer friendly page

These are my health care successes:

(Directions: Please write a few sentences regarding your condition before treatment, and then a few sentences regarding your condition now after receiving the health care we provided.)

Name ________________________

1. Describe your condition. How long had you been suffering?  How did it start?


2. What previous unsuccessful steps had you taken to try to solve your problem?


3. How did you find out about Dr. _____________?


4. Describe what Dr. _______________  did to help you. ( Examination, x-ray, treatment program, etc.)


5. What did Dr. _______ tell you your problem was?


6. Describe your progress, your results , and the benefits you received.


7. How has your life been improved since coming to our office? What can you do now that you could not do before?


8. Words of encouragement for others who have similar problems.


Signature _____________________________ Date_________
I hereby give my permission to publish my success story in whole or in part: (initial) _______

Procedure for
Success Story
Questionnaire Form

When the patient is ready to write their “success story”, have her or him fill out this survey.

Then, you can re-type it and have them sign the new version. Type the following on the bottom of the newly retyped story. When you display the patient's story, you can mention: "(Individual results vary. These accounts were obtained without remuneration and within HIPAA guidelines.)"  You may also want to check with your state association if you have any questions.

I hereby give my permission to publish my success story in whole or in part:
Signature _________________________________   Date:______________________


© Copyright 2008 by

Top of Page

Free Stuff: Articles, Tips, & Tools
Chiropractic and the Golden Goose
Chiropractic and Earth Day
How to Make Your Chiropractic Marketing More Effective: Give a Reason
Swine Flu Posters
Swine Flu Poster-2
“Do Your Part” Patriotic Chiropractic Promotion
Do Your Part Chiropractic Poster
Do Your Part Chiropractic Coupon
No Cell Phone Sign
Health Related Observences - Spring, 2009
Goose Story
Timely Insurance Filing

Petty, Michel & Associates
Practice Growth & Development Since 1988
Voice: (414) 332-4511 Fax: (414) 332-0909
Post: P.O. Box 170882 Whitefish Bay, WI   53217

Creative Commons License
Works in the Articles Section are licensed under a Creative Commons Attribution-Share Alike 2.5 License.