Patient Re-Evaluation Form

2502 N. Johns St, Suite B · Garden City, KS 67846 · (620) 271-0243

Required fields marked * — kept strictly confidential

Patient Identification

First Name *Last Name *

Date of Birth *Re-Evaluation Date *

Chief Complaint *

Overall Progress Since Last Visit / Evaluation

How would you rate your overall progress? *Please describe your progress in your own words

Response to Treatment

Consent for Continued Care

I confirm that the information provided on this re-evaluation form is accurate and complete to the best of my knowledge. I consent to continued chiropractic examination and treatment by the doctors and staff of ProHealth Chiropractic Wellness Centers. I understand I may withdraw this consent at any time and that my provider will use this updated information to adjust my care plan as appropriate.

Patient Signature — Consent for Continued Care *Date *

Typing your name serves as your electronic signature.

This form is protected under HIPAA (45 CFR Parts 160 & 164). PHI is used solely for treatment, payment, and operations.

Patient Re-Evaluation Form

Patient Identification

Overall Progress Since Last Visit / Evaluation

Current Symptom Status

Functional Status

Response to Treatment

Updated Health History

Consent for Continued Care